The nurse notes that a client with depression has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?
Engage the client in non-threatening conversations.
Encourage the client's family to visit more often.
Schedule a daily conference with the social worker.
Encourage the client to participate in group activities.
The Correct Answer is A
Choice A reason: Engaging in non-threatening conversations can help the client feel more comfortable and may encourage communication, which is crucial for clients who are withdrawn due to depression.
Choice B reason: Family visits can be supportive, but the client's withdrawal suggests a need for more direct intervention to encourage communication.
Choice C reason: Scheduling a conference with a social worker is important, but it is not the most immediate intervention for a withdrawn client.
Choice D reason: Group activities may be overwhelming for a client who is noncommunicative and may not be the most suitable initial approach.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2.4"]
Explanation
Step 1: Convert the weight from pounds to kilograms. We know that 1 kg = 2.2 lbs. So, the weight in kg is:
175 lbs ÷ 2.2 = 79.55 kg
Step 2: Calculate the total units of heparin needed. The prescription is for 3 units/kg, so:
3 units/kg × 79.55 kg = 238.65 units
Step 3: Calculate the volume of heparin to administer. The vial is labeled as "100 units/mL", so:
238.65 units ÷ 100 units/mL = 2.39 mL
So, the nurse should administer approximately 2.4 mL of heparin (rounded to the nearest tenth).
Correct Answer is B
Explanation
Choice A reason: Waiting until after the procedure to assess for discomfort does not ensure client safety during the procedure itself. While pain assessment is important, it is not the priority safety intervention in this situation, especially since the client is already mildly confused and could disrupt the sterile field or injure themselves if not properly guided.
Choice B reason: Because the client is mildly confused, there is a risk of them inadvertently reaching into or touching the sterile field during the procedure. The nurse’s priority safety action is to provide clear, simple instructions such as reminding the client to keep their hands away or under the sterile field. This prevents contamination and reduces the risk of infection, protecting both the client and the procedure.
Choice C reason: Pouring cleansing solution onto the sterile cloth field would contaminate the sterile setup, since fluids should only be poured into sterile containers or basins. This action could compromise the sterile field and increase infection risk, making it unsafe practice.
Choice D reason: Informed consent for a procedure like wound debridement must be obtained by the healthcare provider before the procedure begins, not during. While the nurse can verify consent earlier, at the point described in the scenario (when the sterile field is already set up), the immediate priority is to maintain sterility and safety, not obtain consent.
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