Nokea
A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?
- A. Document the client's behavior in the medical record every 1 hr.
- B. Keep staff interactions with the client to a minimum.
- C. Request the provider renew the prescription in 24 hr.
- D. Provide range-of-motion exercises to all extremities every 2 hr.
Correct Answer: D
Rationale: Providing range-of-motion exercises every 2 hours helps to prevent complications associated with immobility, such as muscle atrophy and pressure ulcers. This is a critical safety measure for clients in restraints.
You may also like to solve these questions
A nurse is reinforcing teaching about a new prescription for haloperidol with a client who has schizophrenia. Which of the following statements by the client indicates an understanding of the teaching?
- A. I may be more sensitive to the sun while taking this medication.
- B. The medication may cause urinary incontinence.
- C. I may experience a metallic taste while taking this medication.
- D. The medication may cause ringing in my ears.
Correct Answer: A
Rationale: Haloperidol can increase photosensitivity, causing the skin to be more sensitive to sunlight, potentially leading to sunburn. Patients should be advised to use sunscreen and wear protective clothing. This statement shows the client understands a key side effect.
A nurse is providing information to a client about smoking cessation. Which of the following medications should the nurse include?
- A. Bupropion.
- B. Risperidone.
- C. Aripiprazole.
- D. Quetiapine.
Correct Answer: A
Rationale: Bupropion is an antidepressant also used to aid smoking cessation by reducing cravings and withdrawal symptoms. It’s specifically indicated for this purpose.
A nurse is caring for a client who is experiencing a situational crisis. Which of the following actions should the nurse take first?
- A. Assist with a client referral for social services.
- B. Identify if the client has thoughts of self-harm.
- C. Reinforce teaching on the client's use of coping skills.
- D. Encourage the client to use personal support systems.
Correct Answer: B
Rationale: Identifying thoughts of self-harm is crucial for immediate safety and risk management, making it the priority action. This ensures the client’s well-being is secured before addressing other needs.
A nurse is beginning a therapeutic relationship with a client who has paranoid personality disorder. Which of the following strategies should the nurse plan to use?
- A. Demonstrate a neutral demeanor.
- B. Use an overly friendly approach.
- C. Ask the client why he is suspicious of others.
Correct Answer: A
Rationale: Demonstrating a neutral demeanor helps build trust with a client who has paranoid personality disorder. This non-threatening approach avoids triggering suspicion, fostering a therapeutic relationship.
Nurses' Notes
0800: Client is 3 days postoperative. Currently disoriented to time and place, oriented to self. Client is displaying disorganized thinking, a lack of attention when spoken to, and rambling speech that is incoherent at times. Client attempts to get out of bed without assistance. Changes in client's behavior began the prior evening and client has been awake most of the night. Client has refused to eat or drink since the previous day. Intake and output from previous day: 250 mL intake, 2,500 mL output. Call placed to provider to report findings.
0830: IV fluids initiated by RN. Urine and blood samples collected per provider's prescription. Client continues to be restless.
Vital Signs
• Heart rate: 115/min
• Respiratory rate: 20/min
• Blood pressure: 90/65 mm Hg
• Temperature: 38.6°C (101.5°F)
A nurse is caring for an older adult client who is postoperative.Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 arameters the nurse should monitor to collect data about the client's progress.
- A. Delirium,Depression,Alzheimer's disease,Generalized anxiety disorder
- B. Encourage family members to stay with the client,Assist the client to identify coping skills,Monitor the client's fluid intake and output,Encourage the client to exercise.
- C. Suicidal ideation,Weight loss,Fall risk,Sleep-wake cycle
Correct Answer: A
Rationale: Delirium fits acute postoperative confusion. Family presence reassures, fluid monitoring addresses dehydration, and tracking fall risk and sleep assess safety and recovery.