The nurse is assisting in the care of the client who is on the behavioral health unit.
Select words from the choices below to fill in each blank in the following sentence (Separate using commas).
The nurse should plan to
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: Assigning the client to a negative pressure airflow room is crucial as varicella zoster is highly contagious and can be transmitted through airborne droplets. A negative pressure room helps contain the virus and filters the air, reducing the risk of spread to other patients and healthcare personnel.
Choice B rationale: Administering aspirin is contraindicated in clients with varicella zoster due to the risk of Reye's syndrome, especially in children and adolescents. Aspirin should not be given to children or adolescents with viral infections because it can cause serious complications affecting the liver and brain.
Choice C rationale: Having visitors remain at least 0.91 m (3 feet) away from the client is insufficient. Varicella zoster is highly contagious and requires more stringent airborne precautions, including having visitors wear masks and follow proper hygiene protocols to minimize the risk of transmission.
Correct Answer is A
Explanation
Choice A rationale:
"Prednisone can cause blood glucose levels to increase." Rationale: This statement is accurate. Prednisone is a corticosteroid medication known to cause hyperglycemia (high blood glucose levels) as a side effect. It is important for the nurse to monitor the client's blood glucose levels while they are taking prednisone, especially if the client has preexisting diabetes or risk factors for diabetes.
Choice B rationale:
"Older adults are at risk for developing type 1 diabetes mellitus." Rationale: This statement is incorrect. Type 1 diabetes mellitus typically develops in childhood or early adulthood and is characterized by autoimmune destruction of the insulin-producing cells in the pancreas. Older adults are more at risk for developing type 2 diabetes, which is different from type 1 diabetes in terms of its etiology and pathophysiology.
Choice C rationale:
"Having COPD causes blood glucose levels to fluctuate." Rationale: This statement is not accurate. COPD (Chronic Obstructive Pulmonary Disease) primarily affects the respiratory system and does not directly cause blood glucose level fluctuations. Blood glucose levels can be affected indirectly in some cases due to factors like medications or stress associated with the illness, but it is not a direct result of COPD.
Choice D rationale:
"Albuterol treatments can cause blood glucose levels to decrease." Rationale: This statement is not a typical effect of albuterol treatments. Albuterol is a bronchodilator commonly used to treat respiratory conditions like COPD and asthma. It is not known to cause significant decreases in blood glucose levels.
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