A client on an inpatient unit angrily says to a nurse. "Peter is not cleaning up after himself in the community bathroom. You need to address this problem. Which is the appropriate nursing response?

I'll talk to Peter and present your concerns."

I can see that you are angry. Let's discuss ways to approach Peter with your concerns."

Why are you overeacting to the issue

You should bring this to the attention of your treatment team.

Answer and Explanation

The Correct Answer is A

A. "I can see that you are angry. Let's discuss ways to approach Peter with your concerns."

This response is empathetic and invites the client to discuss their concerns. However, it doesn't explicitly address the client's request for the nurse to take action. The more appropriate approach would involve the nurse taking direct responsibility for addressing the issue.

B. "Why are you overreacting to the issue?"

This response may be perceived as dismissive and judgmental. It does not validate the client's concerns or address the issue constructively.

C. "You should bring this to the attention of your treatment team."

While involving the treatment team is important, the client has directly approached the nurse with a concern. It is appropriate for the nurse to take the initial step in addressing the issue directly rather than immediately redirecting the client to the treatment team.

D. "I'll talk to Peter and present your concerns."

This is the most appropriate response. It acknowledges the client's concerns, takes responsibility for addressing the issue, and ensures that the client's voice is heard. The nurse can discuss the matter with Peter and work towards a resolution.

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Correct Answer is D

Explanation

A. Implement the client's behavioral modification plan:

While addressing the client's behavioral modification plan is important, it may not be the immediate priority when the client has self-inflicted cuts. Ensuring physical safety and assessing the extent of the injury take precedence.

B. Document the size and location of the cuts:

Documentation is important, but it is not the first action to be taken. The immediate concern is to assess the physical condition of the cuts and address any potential risks.

C. Administer a tetanus antitoxin:

Administering a tetanus antitoxin may be necessary depending on the nature and depth of the cuts. However, it is not the first action. First, a thorough inspection of the cuts is needed to determine the appropriate course of action.

D. Inspect the cuts for debris:

This is the most appropriate first action. Inspecting the cuts for debris helps determine the severity of the wounds and whether there is a risk of infection. It also allows the nurse to assess the need for further medical intervention.

A. Dry mouth and urinary retention B. Akinesia and insomnia C. Sore throat, fever, and malaise D. Akathisia and hypersalivation

Correct Answer is C

Explanation

A. Dry mouth and urinary retention: These symptoms are not typically associated with the side effects of clozapine. Dry mouth is a common side effect of many antipsychotic medications, but urinary retention is not a typical side effect of clozapine.

B. Akinesia and insomnia: Akinesia (lack of movement) is not a common side effect of clozapine. Insomnia can occur with various antipsychotic medications but does not typically warrant immediate intervention unless severe or persistent.

C. Sore throat, fever, and malaise: These symptoms can indicate a potentially serious side effect known as agranulocytosis, which is a significant reduction in white blood cell count. Clozapine is associated with an increased risk of agranulocytosis. If a client experiences symptoms such as sore throat, fever, or malaise, it may indicate a severe drop in white blood cell count, and immediate medical attention is necessary.

D. Akathisia and hypersalivation: Akathisia (restlessness) is a known side effect of antipsychotic medications, but it is not typically associated with immediate severe medical risks. Hypersalivation is a common side effect but does not usually require immediate intervention unless severe.

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A client on an inpatient unit angrily says to a nurse. "Peter is not cleaning up after himself in the community bathroom. You need to address this problem. Which is the appropriate nursing response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A client diagnosed with schizophrenia is prescribed clozapine (Clozaril). Which client symptoms related to the side effects of this medication should prompt a nurse to intervene immediately?

Correct Answer is C

Explanation

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