Nokea
A nurse is caring for a patient who attacked a friend and is now admitted to the psychiatric unit. Which of the following actions should the nurse take first? Which action should the nurse take first for an aggressive patient?
- A. Establish a patient relationship.
- B. Explore the truth of the patient's statements.
- C. Set behavioral limits for the patient.
- D. Explain to the patient that the behavior was unacceptable.
Correct Answer: C
Rationale: The correct answer is C: Set behavioral limits for the patient. This is the first action the nurse should take to ensure the safety of the patient and others. By setting clear boundaries and limits, the nurse can help manage the patient's aggressive behavior and prevent any further harm. Establishing a patient relationship (A) is important but secondary to ensuring immediate safety. Exploring the truth of the patient's statements (B) can be addressed once the aggressive behavior is under control. Explaining to the patient that the behavior was unacceptable (D) may not be effective in the heat of the moment and should come after setting limits.
You may also like to solve these questions
A nurse is evaluating a patient who is suffering from prostatic hypertrophy. What symptoms associated with urinary retention should the nurse anticipate? What symptoms of urinary retention should the nurse anticipate?
- A. Sensation of pressure
- B. Dysuria
- C. Bladder distension
- D. Tenderness over the symphysis pubis
Correct Answer: A,B,C,D
Rationale: The correct answer includes symptoms associated with urinary retention in a patient with prostatic hypertrophy. A: Sensation of pressure is expected due to the bladder being unable to empty completely. B: Dysuria can occur as the bladder becomes overfilled. C: Bladder distension is a common symptom as the bladder fills up but cannot empty fully. D: Tenderness over the symphysis pubis may be present due to the pressure on surrounding structures. Other choices are incorrect as they do not directly relate to urinary retention symptoms in this context.
A provider has prescribed quetiapine 50 mg PO, divided equally every 12 hours for 3 days. The available medication is quetiapine 25 mg tablets. How many tablets should the nurse administer per dose on the third day? How many quetiapine tablets per dose on day 3?
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: A
Rationale: The correct answer is A: 1 tablet. On the third day, the total dose required is 50 mg, which is equivalent to 2 tablets of 25 mg each. Since the dose needs to be divided equally every 12 hours, the nurse should administer 1 tablet per dose on the third day. Choice B (2 tablets) is incorrect as it would result in an overdose of 100 mg. Choices C (3 tablets) and D (4 tablets) are also incorrect for the same reason.
A nurse is formulating a care plan for a patient recovering from severe burns. Which of the following strategies should the nurse incorporate to provide emotional support? Which strategy provides emotional support for burn recovery?
- A. Engage in conversation with the patient during wound care.
- B. Ensure the patient's room is kept tidy by support staff.
- C. Keep the patient's family informed about his condition.
- D. Rotate the nursing staff to provide the patient with varied interactions.
Correct Answer: A
Rationale: The correct answer is A: Engage in conversation with the patient during wound care. This strategy provides emotional support by offering the patient a distraction and a sense of connection during a potentially painful and distressing procedure. It allows the patient to express their feelings and concerns, fostering a therapeutic relationship.
Choice B: Ensuring the patient's room is tidy is important for the patient's physical comfort but does not directly address emotional support.
Choice C: Keeping the patient's family informed is crucial for communication but may not directly provide emotional support to the patient.
Choice D: Rotating nursing staff may offer varied interactions, but consistency and building rapport with the same caregiver can be more beneficial for emotional support in this context.
A nurse in the emergency department is attending to a patient exhibiting symptoms of a myocardial infarction. Which of the following actions should the nurse prioritize? Which action should the nurse prioritize for myocardial infarction?
- A. Initiate oxygen therapy.
- B. Obtain a blood sample.
- C. Attach the leads for a 12-lead ECG.
- D. Insert an IV catheter.
Correct Answer: A
Rationale: The correct answer is A: Initiate oxygen therapy. In a myocardial infarction, the priority is to ensure adequate oxygen supply to the heart muscle to prevent further damage. Oxygen therapy helps increase oxygen delivery to the heart, reducing the workload on the heart muscle. This action can potentially limit the size of the infarction and improve the patient's outcome. Obtaining a blood sample (B) can provide valuable information but is not as urgent as ensuring oxygen supply. Attaching leads for a 12-lead ECG (C) is important for diagnosing the myocardial infarction but does not directly address the immediate need for oxygen. Inserting an IV catheter (D) may be necessary for administering medications, but oxygen therapy takes precedence in this situation.
A nurse is caring for a patient who is receiving continuous bladder irrigation following a transurethral resection of the prostate. Which of the following findings should the nurse report to the provider? Which finding should the nurse report during bladder irrigation?
- A. Urine output of 200 mL/hr
- B. Pink-tinged urine
- C. Clots in the drainage bag
- D. Bladder spasms
Correct Answer: C
Rationale: The correct answer is C: Clots in the drainage bag. This finding should be reported to the provider because it may indicate bleeding or clot formation, which can obstruct the catheter and impair the irrigation process. Clots can also increase the risk of urinary retention or infection. Reporting this finding promptly allows the provider to assess the patient's condition and take appropriate interventions to prevent complications.
Incorrect choices:
A: Urine output of 200 mL/hr is within the expected range for continuous bladder irrigation and does not necessarily indicate a problem.
B: Pink-tinged urine is a common finding following prostate surgery and is expected during bladder irrigation.
D: Bladder spasms are common after prostate surgery and can be managed with appropriate medications.
E, F, G: These choices are not provided, but they would be incorrect as they are not related to complications of bladder irrigation post-prostate surgery.