A client on the mental health unit has been displaying signs of agitation, such as scowling and pacing rapidly up and down the hallway for several minutes.
Which behaviors should the nurse prioritize for monitoring?
Periodic sighing and shaking of the head.
Decreased activity level and change in affect.
Repeated requests for attention from the nurse.
Argumentativeness and use of profanity.
Correct Answer : A,C,D
Choice A rationale
Periodic sighing and shaking of the head can be signs of agitation and distress. These behaviors may indicate that the client is struggling to manage their emotions and may need additional support or intervention.
Choice B rationale
A decreased activity level and change in affect can be signs of many different mental health conditions, but they are not typically associated with agitation. Therefore, while these behaviors should be monitored, they are not the priority in this situation.
Choice C rationale
Repeated requests for attention from the nurse can be a sign of agitation. This behavior may indicate that the client is feeling distressed and is seeking help in managing their emotions.
Choice D rationale
Argumentativeness and use of profanity are clear signs of agitation. These behaviors can escalate quickly and may pose a risk to the safety of the client and others on the unit.
Therefore, these behaviors should be prioritized for monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While it’s true that phantom limb pain can be a normal post-surgical sensation, simply reassuring the patient doesn’t address the pain they’re experiencing.
Choice B rationale
Guiding in moving the unaffected limb to override the sensation being experienced is not a recommended intervention for phantom limb pain. Phantom limb pain is a complex phenomenon that is not simply overridden by movement of other body parts.
Choice C rationale
Explaining that the sensations of tingling and pain are not real may invalidate the patient’s experience. Phantom limb pain is a real phenomenon experienced by many amputees. It’s not just a sensation; it’s a type of neuropathic pain that can be severe and debilitating.
Choice D rationale
Affirming that a prosthetic with physical therapy will gradually improve the symptoms is the best non-pharmacological intervention among the choices. Physical therapy, including mirror therapy and other desensitization techniques, can help manage phantom limb pain. The use of a prosthetic can help the patient regain function and mobility, which can also improve their overall well-being and potentially reduce the perception of phantom limb pain.
Correct Answer is B
Explanation
Choice A rationale
Verifying that the nurse has gathered the necessary supplies is important, but it is not the most critical action in this scenario. The new nurse has already gathered the necessary supplies for the procedure.
Choice B rationale
This is the correct answer. A transparent dressing is preferred over a gauze dressing for securing an IV catheter. It allows for easy inspection of the insertion site for signs of infection.
Choice C rationale
Ensuring that the gauze dressing is taped securely in place is not the most critical action in this scenario. As mentioned, a transparent dressing is generally preferred for securing an IV catheter.
Choice D rationale
While inspecting the secured IV site after the insertion procedure is important, advising the nurse to use a transparent dressing over the site is a more immediate need. This will allow for continuous visual inspection of the site.
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.