When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?

Request backup from the staff.

Stand in the doorway.

Provide for personal space.

Encourage the client to sit down.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Requesting backup from the staff may be necessary if the situation escalates further, but it is not the initial action to take. Providing for personal space and attempting to de-escalate the situation should come first.

Choice B rationale:
Standing in the doorway may not be the most effective approach because it doesn't actively address the client's agitation or attempt to de-escalate the situation.

Choice C rationale:
Providing personal space is an important initial intervention when dealing with an agitated client. This approach helps maintain safety for both the nurse and the client and can reduce the perception of threat or intrusion.

Choice D rationale:
Encouraging the client to sit down may be a helpful de-escalation technique, but it should come after providing for personal space to ensure safety and reduce tension.

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Correct Answer is A

Explanation

Choice A Rationale:
Ecchymotic blood accumulations (bruises) are indicative of possible trauma or injury to the scalp. In this case, it suggests that the hair loss is likely due to physical manipulation (such as pulling or arranging the hair to cover bald spots) rather than a medical condition.

Choice B rationale:
This choice suggests that evidence of patches of lost hair would be indicative of non-disease-related hair loss. However, this is not necessarily true. Medical conditions, such as alopecia areata, can also cause patchy hair loss without physical trauma. Therefore, it is not a definitive indicator that hair loss is not disease-related.

Choice C rationale:
Episodic complaints of pruritus (itching) could be associated with various scalp conditions, including those that lead to hair loss. Itching alone does not rule out disease-related hair loss. In fact, some medical conditions can cause both itching and hair loss.

Choice D rationale:
Erythema (redness) of localized lesions may suggest inflammation but does not necessarily indicate non-disease-related hair loss. Medical conditions can also cause localized inflammation and hair loss.

A. Muscle cramps B. Tingling sensation in her arms and legs C. Lightheadedness D. Fatigue E. 68-year-old with a history of diabetes, hypertension F. Blood Pressure: 146/82 mmHg G. Heart Rate: 114 bpm H. Temperature: 98.2 °F

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

Explanation

The assessment findings that require immediate follow-up by the nurse are: muscle cramps, tingling sensation in arms and legs, and lightheadedness.

These are signs of electrolyte imbalance, which can be caused by missed dialysis sessions, dehydration, or infection. Electrolyte imbalance can lead to serious complications such as cardiac arrhythmias, seizures, or coma.

The nurse should monitor the client's vital signs, neurological status, and cardiac rhythm, and notify the physician for further orders. The nurse should also assess the client's fluid status, hydration, and nutritional intake, and provide education on the importance of adhering to the dialysis schedule and dietary restrictions.

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When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease-related?

Correct Answer is A

Explanation

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

Explanation

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