A 70yearold client is admitted to the locked psychiatric unit, diagnosed with delirium. Later in the day, he tries to get out of the locked unit several times. He yells, "I have to leave and get to my barber. I see him every Wednesday. Let me out!"
Which of the following would be the most therapeutic response by the nurse?
"You need to come and take a shower before you can go get your hair cut."
"Please stop banging on the door. Your room is right over there."
"The door is locked so that you don't leave and get hurt."
"You are in the hospital, and I'm your nurse."
The Correct Answer is C
A. This response does not directly address the client's concern and may be perceived as dismissive.
B. This response does not provide a clear explanation for the locked door and may not effectively address the client's agitation.
C. This response provides a clear and honest explanation for the locked door, ensuring the client's safety, which is the priority.
D. This response acknowledges the situation but does not provide a clear explanation for the locked door.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct. Amitriptyline, like other tricyclic antidepressants, can cause orthostatic hypotension, which is a drop in blood pressure when changing position from lying to standing.
B) Incorrect. Diarrhea is not a common side effect of amitriptyline.
C) Incorrect. Weight gain is more commonly associated with amitriptyline, not weight loss.
D) Incorrect. Excessive salivation is not a typical side effect of amitriptyline.
Correct Answer is ["B","C","D"]
Explanation
A) Incorrect. While it's important to avoid dehydration, this option is not specific to lithium use.
B) Correct. Lithium can cause dehydration, so it's crucial for the client to drink adequate fluids daily.
C) Correct. A low sodium diet is important while taking lithium, as high sodium levels can affect lithium absorption and potentially lead to toxicity.
D) Correct. Routine blood work is necessary to monitor lithium levels and ensure the client's levels remain within the therapeutic range.
E) Incorrect. Dependency is not a common concern with lithium.
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