The psychiatric nurse is talking to a newly admitted client when another male client, who is diagnosed with antisocial behavior, intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" How should the nurse respond to this client?

Put his behavior on extinction and continue talking with the newly admitted client.

Inform him that the nurse is busy admitting a new client and will talk to him later.

Encourage him to go to the nurse's station and talk with another nurse.

Introduce him to the newly admitted client and ask him to join in the conversation.

Answer and Explanation

The Correct Answer is B

A. Ignoring the client's behavior (putting it on extinction) may escalate the situation, as clients with antisocial behavior often do not respond well to being ignored.

B. Informing him that the nurse is busy and will talk to him later sets clear boundaries while acknowledging his request. It helps manage his behavior without reinforcing negative actions.

C. Encouraging him to talk with another nurse may not address his immediate need for attention and could result in further disruptive behavior.

D. Introducing him to the newly admitted client may not be appropriate as it could disrupt the admission process and potentially intimidate the new client.

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Correct Answer is A

Explanation

A. Maintaining strict intake and output is crucial in managing septic shock as it helps to monitor fluid balance, which is essential for managing hypovolemia and ensuring adequate perfusion.

B. While assessing warmth of extremities is important, it is not as directly related to the immediate management of septic shock as monitoring intake and output.

C. Monitoring blood glucose levels is important, especially in septic patients, but it is not the primary focus in the initial management of septic shock.

D. Keeping the head of the bed raised 45 degrees can help with breathing but is not the most critical intervention in the immediate management of septic shock.

A. Verify that Client B has two units of packed cells available. B. Ask the dietitian to add a banana to Client C's breakfast tray. C. Increase Client A's oxygen to 4 L/minute via nasal cannula. D. Move Client D into an isolation room 24 hours before surgery.

Correct Answer is A

Explanation

A. Client B’s hemoglobin is significantly low, indicating the need for a blood transfusion to improve oxygen-carrying capacity.

B. Client C’s potassium level is within normal limits, so there is no immediate need to add a banana.

C. Client A’s oxygen saturation is acceptable, so increasing the oxygen is unnecessary.

D. Client D’s elevated WBC count may indicate infection, but moving them to isolation before surgery is not required based solely on this finding.

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The psychiatric nurse is talking to a newly admitted client when another male client, who is diagnosed with antisocial behavior, intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" How should the nurse respond to this client?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribes a sepsis protocol to be initiated. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

After removing a client's dressing that is saturated with sanguineous drainage, where should the nurse place the dressing?

The psychiatric nurse is talking to a newly admitted client when another male client, who is diagnosed with antisocial behavior, intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" How should the nurse respond to this client?

Patient Data Exhibits To start the client on oxygen as prescribed, which item(s) should the nurse collect from the supply room? Select all that apply.

The nurse is assessing a client who recently had an upper respiratory infection and now presents to the emergency department with lower extremity numbness and difficulty swallowing. Based on these findings, this client is at greatest risk for which pathophysiological condition?

The nurse is preparing a community outreach program on primary disease prevention. Which topic should the nurse plan to include in this event?

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?