A client is admitted to the mental health unit for feelings of depression secondary to a positive HIV report. To provide a safe milieu for this client, which action should the nurse take?

Ensure that prescribed medications are kept in a safe place in the room.

Remove soft drink cans from the nurse's desk and patient lounge.

Replace paper trash bags with plastic biohazard bags.

Take the client's cellular telephone and provide a telephone in the room.

Answer and Explanation

The Correct Answer is B

Rationale

A. This action is important to prevent unauthorized access to medications by the client or other patients. However, this is not the priority

B. Soft drink cans can potentially be used to harm oneself or others (e.g., by smashing or as a cutting tool). Removing these items helps to reduce the risk of self-injury or harm to others.

C. This action is typically done to safely dispose of any items that may be considered biohazardous, such as used tissues, bandages, or any items contaminated with bodily fluids. It helps to maintain infection control and prevent exposure to potentially infectious materials.

D. In some mental health units, clients may not be allowed to have personal electronic devices due to concerns about confidentiality, safety, or potential disruption. Providing a unit-controlled telephone allows staff to monitor communication and ensure it is appropriate and supportive

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Correct Answer is B

Explanation

Rationale

A. This intervention is crucial because bariatric surgery can have significant psychological impacts. Many individuals who undergo such procedures may experience changes in mood, body image issues, and emotional challenges. However, it is not a priority

B. Sequential compression stockings are used to prevent deep vein thrombosis (DVT) and promote circulation in clients undergoing surgery, particularly those with obesity who are at higher risk for venous thromboembolism. This intervention is important to prevent serious complications associated with immobility and surgery.

C. This option is not appropriate immediately after gastroplasty. Bariatric surgery, such as gastroplasty, typically involves restrictive procedures that limit the amount of food a person can consume. Providing a wide variety of meal choices contradicts the dietary restrictions and guidelines that are crucial for successful outcomes post-surgery.

D. While urinary incontinence can be a concern in some individuals, it is not directly related to bariatric surgery or the client's primary health concerns of obesity, diabetes mellitus, and hypertension. Monitoring for urinary incontinence may be important in other clinical contexts but is not a priority in the immediate postoperative period of gastroplasty.

A. Reposition the stethoscope over the brachial artery. B. Note the presence of an auscultatory gap. C. Continue with the blood pressure assessment. D. Reinflate the cuff to a higher number.

Correct Answer is B

Explanation

Rationale

A. Repositioning the stethoscope or reinflating the cuff may be necessary if the sounds are unclear or if there is difficulty in hearing the Korotkoff sounds, but these actions come after noting any auscultatory gap.

B. It's characterized by a period of silence between the appearance and disappearance of sounds. Noting its presence is important for accurately recording the blood pressure readings, as failure to recognize an auscultatory gap could lead to underestimating the systolic pressure.

C. After repositioning the stethoscope or noting the presence of an auscultatory gap, the nurse should proceed with the blood pressure assessment.

D. If the cuff was not inflated adequately during the initial inflation, the nurse may not have occluded the artery completely, leading to inaccurate readings. However, in this scenario where Korotkoff sounds

are heard, it indicates that the cuff pressure was sufficient to occlude and then release the artery's blood flow.

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A client is admitted to the mental health unit for feelings of depression secondary to a positive HIV report. To provide a safe milieu for this client, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

Correct Answer is B

Explanation

The nurse has reviewed the client's chart. Exhibits Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse recognizes that this client is dropdown due to dropdown

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