The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement?

Use firmness and direct the client to sit for awhile.

Suggest to the client that he take a walk.

Move the client to a quiet place on the unit.

Encourage the client to use the punching bag

Answer and Explanation

The Correct Answer is C

Delusions and loss of control can be distressing for the client and potentially disruptive to the unit environment. Moving the client to a quiet place helps create a calm and less stimulating environment, which can help reduce agitation and promote a sense of safety and security.

Using firmness and directing the client to sit for a while may escalate the situation and increase the client's distress. It is important to approach the client with empathy and provide a supportive environment rather than exerting control through firmness.

Suggesting the client take a walk or encouraging the client to use a punching bag may not be appropriate if the client is already displaying signs of agitation and losing control. These interventions may not address the underlying causes of the delusions and could potentially worsen the situation.

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Correct Answer is ["A","C","D"]

Explanation

A) Correct- This is correct advice. Juice is not recommended for infants due to its high sugar content and lack of essential nutrients. It can contribute to excessive calorie intake and dental caries.
B) Incorrect- This is not accurate for a 9-month-old infant. By 9 months, most infants have already started to transition to solid foods, and their primary source of nutrition should be from a variety of solid foods, not formula.
C) Correct- This is correct advice. By 9 months, infants can begin to consume a variety of complementary foods to meet their nutritional needs. Adding raw fruit, cheese, or cooked vegetables can provide important nutrients and help introduce different tastes and textures.
D) Correct- As infants transition to solid foods, they typically require more frequent meals and snacks to meet their energy and nutrient needs. Breast milk or formula intake may also gradually decrease as solid foods are introduced.
E) Incorrect- Fluoride supplementation may be considered based on the fluoride content of the water supply and the child's risk of dental caries. However, this advice is not specific to the child's nutrition and feeding progression.
F. Incorrect- At 9 months, infants should not transition to whole cow's milk as their main source of nutrition. Breast milk or infant formula remains the primary source of nutrition, and cow's milk can be introduced as a beverage and ingredient in cooking after the first year of life.

A. Evaluate glucose levels before and after meals. B. Assess the serum potassium level every 4 hours. C. Monitor and document strict intake and output. D. Obtain a 12-lead electrocardiogram daily.

Correct Answer is B

Explanation

The client's serum potassium level is elevated at 6.0 mEq/L (6.0 mmol/L), which is above the normal reference range of 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L).

Hyperkalemia can have significant cardiac implications, including the potential for life-threatening dysrhythmias. Therefore, close monitoring of the serum potassium level is crucial to assess the effectiveness of interventions and ensure that potassium levels are within a safe range.

While monitoring glucose levels before and after meals is important for clients receiving insulin therapy, in this scenario, the primary concern is the elevated potassium level.

The nurse should prioritize frequent assessment of the serum potassium level to guide appropriate management and prevent complications associated with hyperkalemia.

Monitoring and documenting strict intake and output are important for assessing fluid balance and renal function, but in this case, the elevated potassium level takes precedence as it poses a more immediate risk to the client's well-being.

Obtaining a 12-lead electrocardiogram (ECG) daily may be indicated in some cases of hyperkalemia, as certain ECG changes can be associated with elevated potassium levels. However, the more critical aspect is monitoring the potassium level itself, as ECG changes can occur rapidly and may not always be detectable on a daily basis.

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The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse at the 9-month visit reviews the child's height, weight, and feeding progression history. What should the nurse advise the parents concerning the child's nutrition? Select all that apply

Correct Answer is ["A","C","D"]

Explanation

Correct Answer is B

Explanation

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