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.
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale
A. Older adults are more susceptible to medication side effects due to changes in metabolism and polypharmacy. Reviewing the client's current medications, including over-the-counter medications for allergies and insomnia, can identify potential culprits.
B. Some medications used for allergies or insomnia, such as antihistamines or sedatives, can cause EPS in older adults. EPS include symptoms like tremors, rigidity, or involuntary movements. These symptoms can indicate adverse reactions that require immediate attention and adjustment of medication.
C. These symptoms could be side effects of medications commonly used for allergies and insomnia. They may also indicate other underlying health issues or medication interactions. Assessing these symptoms helps in determining their severity and whether they require further evaluation or intervention.
D. Social isolation can contribute to changes in behavior, especially in older adults. While social activities are beneficial for mental health, in this case, addressing the potential medication-related issues (options A and B) takes precedence to ensure the client's safety and well-being.
Correct Answer is A
Explanation
Rationale
A. Informing the information services department allows them to be aware of the issue promptly. They can then investigate the cause of the system failure and initiate appropriate measures to restore the system. It's important to involve IT professionals who are responsible for maintaining and troubleshooting the computer system.
B. While having access to patient information is crucial, printing from a backup server might not be immediately feasible or necessary if the primary system is expected to be restored soon. The nurse should first notify IT services to resolve the issue. If access to patient records is urgently needed and cannot be delayed, then printing from a backup server could be considered after notifying IT services.
C Waiting passively without taking action may delay the resolution of the issue. It's important for the nurse to proactively notify the information services department so they can begin troubleshooting and rebooting the system if necessary.
D. Labeling information as a late entry should only be considered once the system is back online and accessible. It should be done according to facility policies and procedures regarding late entries in medical records. However, this should not be the first action because the primary concern is to restore the functionality of the computer documentation system.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.