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The nurse is assisting in the care of the client who is on the behavioral health unit.

Exhibits

Select words from the choices below to fill in each blank in the following sentence (Separate using commas).

The nurse should plan to

and

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}

The correct answer is choice A and E.

Choice A rationale:

The nurse should plan to ask the client what they are hearing. This is a therapeutic communication technique known as seeking clarification. It allows the nurse to gain more information and understand the client’s perspective. It can also help the client feel heard and validated, which can build trust and rapport.

Choice B rationale:

Telling the client their hallucinations are not real is not recommended. While it’s true that the hallucinations are not real, from the client’s perspective, they are very real and can be very frightening. Telling them otherwise can come across as dismissive and invalidating, which can damage the therapeutic relationship.

Choice C rationale:

Escorting the client to a group meeting may not be appropriate at this time. Given the client’s current state of agitation and confusion, they may not be able to participate effectively in a group setting. It could also potentially disrupt the group dynamic.

Choice D rationale:

Restraining the client should be a last resort and only used when the client is a danger to themselves or others. In this case, while the client is agitated and confused, they do not appear to be an immediate danger.

Choice E rationale:

Reducing excess stimulation around the client can be beneficial in this situation. Excess stimulation can exacerbate symptoms of psychosis such as hallucinations and agitation. By creating a calm and quiet environment, it can help reduce these symptoms and help the client feel more at ease.


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Related Questions

Correct Answer is D

Explanation

Choice A rationale:

Hyperglycemia is not typically associated with tranylcypromine, a monoamine oxidase inhibitor (MAOI) MAOIs can affect blood pressure regulation, but hyperglycemia is not a common adverse effect of this medication.

Choice B rationale:

Hematuria (blood in the urine) is not a known adverse effect of tranylcypromine. This symptom is not directly related to the use of MAOIs.

Choice C rationale:

Tinnitus (ringing in the ears) is not a common adverse effect of tranylcypromine. MAOIs can affect the cardiovascular system, but tinnitus is not a typical manifestation.

Choice D rationale:

Tranylcypromine, an MAOI, can cause hypertension (high blood pressure) as an adverse effect due to its ability to inhibit the breakdown of tyramine in the body. When tyramine-rich foods are ingested, there can be a sudden release of norepinephrine, leading to a hypertensive crisis. Therefore, monitoring for hypertension is essential when a client is taking tranylcypromine and has ingested tyramine-rich foods.

Correct Answer is A

Explanation

The correct answer is A. "We need to check the client's urine output every hour."

Choice A rationale:

Monitoring urine output every hour is crucial for assessing kidney function and ensuring the urostomy is functioning properly, especially in the immediate postoperative period.

Choice B rationale:

A pale stoma is not an expected finding. A healthy stoma should be pink to red. A pale stoma could indicate inadequate blood supply and needs immediate evaluation.

Choice C rationale:

While some blood or small clots in the urine might be expected shortly after surgery, this is not a standard instruction to give. Any significant or persistent bleeding should be reported and assessed promptly.

Choice D rationale:

Restricting fluid intake is generally not recommended after surgery unless specifically ordered. Adequate hydration is important for recovery and maintaining urinary output.

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