Nokea
A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?
- A. Document the client's behavior prior to being placed in seclusion,
- B. Assess the client's behavior once every hour
- C. Offer fluids every 2 hr.
- D. Discuss with the client his inappropriate behavior prior to seclusion
Correct Answer: A
Rationale: The correct answer is A: Document the client's behavior prior to being placed in seclusion. This is important for legal and clinical reasons as it provides a clear record of the client's behavior leading up to seclusion, ensuring transparency and accountability. Assessing behavior once every hour (choice B) may not be sufficient for monitoring the client's condition in seclusion. Offering fluids every 2 hours (choice C) is important for hydration but not directly related to seclusion. Discussing inappropriate behavior with the client (choice D) may escalate the situation and is not recommended in this scenario.
You may also like to solve these questions
Which of the following findings should the nurse expect?
- A. Head circumference exceeds chest circumference
- B. Palpable fontanels
- C. Natural loss of deciduous teeth
- D. Nontender, protruding abdomen
Correct Answer: D
Rationale: The correct answer is D: Nontender, protruding abdomen. This finding is expected in a child with kwashiorkor, a form of severe protein-energy malnutrition. The nontender, protruding abdomen is due to fluid accumulation in the abdomen (ascites) and the lack of muscle mass. This is a key characteristic of kwashiorkor. The other choices are incorrect because: A) Head circumference exceeding chest circumference is not a typical finding in children; B) Fontanels should be soft and flat in infants, not palpable; C) Natural loss of deciduous teeth occurs around age 6-12 years, not in infancy.
Complete the following sentence by using the list of options. The client is at risk of----- as evidenced by-------
- A. fluid volume overload
- B. anemia
- C. hypostatic pneumonia
- D. calorie deficiency
- E. orthostatic hypotension
- F. immobility
Correct Answer: C,F
Rationale: Immobility increases the risk of hypostatic pneumonia, especially in clients with paraplegia.
Which of the following statements by the parent indicates an understanding of the teaching?
- A. After 5 to 10 minutes when the breast is emptied, my baby should be removed from the breast.â€
- B. Manually expressing my milk will decrease my milk supply.
- C. My baby should always start on the same breast when feeding.â€
- D. The more my baby is at the breast sucking, the mare milk I will produce.â€
Correct Answer: D
Rationale: The correct answer is D because it reflects an understanding of the concept of supply and demand in breastfeeding. The statement acknowledges that the more the baby suckles, the more milk the parent will produce. This aligns with the principle that frequent and effective nursing stimulates milk production.
Choice A is incorrect because it suggests limiting nursing time, which can hinder milk production. Choice B is incorrect as manual expression can actually help increase milk supply. Choice C is incorrect as it is recommended to offer both breasts during a feeding session to ensure the baby receives enough hindmilk.
A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?
- A. \| can continue to take St John's wort while taking this medication
- B. I know It will be& couple of weeks before the medication helps me feel better
- C. I expect this medication to raise my blood pressure
- D. I should take this medication on an empty stomach
Correct Answer: B
Rationale: Correct Answer: B: "I know It will be a couple of weeks before the medication helps me feel better"
Rationale: Amitriptyline is a tricyclic antidepressant that can take several weeks to reach its full therapeutic effect. This statement shows the client understands the delayed onset of action of the medication, managing expectations. This is crucial in ensuring the client does not become discouraged if they do not feel immediate improvement.
Incorrect Choices:
A: "I can continue to take St John's wort while taking this medication" - St John's wort can interact with amitriptyline, leading to increased side effects and reduced effectiveness.
C: "I expect this medication to raise my blood pressure" - Amitriptyline can indeed cause hypotension, not hypertension.
D: "I should take this medication on an empty stomach" - Amitriptyline should be taken with food to reduce gastrointestinal side effects and improve absorption.
The nurse should notify the provider for which of the following findings?
- A. Report of discomfort at the insertion site
- B. Heart rate 90/min
- C. Bounding pulses in the affected extremity
- D. Hematoma over the insertion site
Correct Answer: D
Rationale: The correct answer is D: Hematoma over the insertion site. This finding indicates potential internal bleeding, which can lead to complications. Notify the provider to assess and manage promptly. A: Discomfort at insertion site is common post-procedure and can be managed with appropriate interventions. B: Heart rate of 90/min is within normal range and does not require immediate provider notification. C: Bounding pulses in the affected extremity may indicate adequate perfusion and is not a concerning finding.