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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is C,A,B,D

Explanation

Step 1: Complete a focused assessment. The first step in managing a patient with abdominal pain and distention, vomiting, and constipation is to perform a focused assessment. This includes assessing the patient’s vital signs, pain level, abdominal distention, bowel sounds, and any other relevant physical findings.

Step 2: Elevate the head of the bed. Elevating the head of the bed can help reduce the risk of aspiration, especially in a patient who has recently vomited.

Step 3: Send the emesis sample to the lab. Analyzing the vomitus can provide important information about the possible causes of the patient’s symptoms. For example, the presence of blood could suggest a gastrointestinal bleed.

Step 4: Offer PRN pain medication. After the initial assessment and interventions, the nurse should address the patient’s comfort. Pain management is an important part of patient care, but in this scenario, it is not the highest priority.

A. Administer PRN oxygen. B. Provide high protein snacks. C. Monitor glucose levels every 4 hours. D. Schedule frequent rest periods.

Correct Answer is D

Explanation

Choice D rationale
Scheduling frequent rest periods can help manage the fatigue and concentration problems reported by the client. These symptoms are common in clients with CKD and elevated BUN and serum creatinine levels.
Choice A rationale
Administering PRN oxygen may not be necessary unless the client is showing signs of respiratory distress or hypoxia. There is no indication of this in the question.
Choice B rationale
Providing high protein snacks is not recommended for clients with CKD. High protein diets can increase the workload on the kidneys and worsen kidney function.
Choice C rationale
Monitoring glucose levels every 4 hours is not directly related to the client’s reported symptoms or the elevated BUN and serum creatinine levels.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C,A,B,D

Explanation

A client with chronic kidney disease (CKD) has elevated blood urea nitrogen (BUN) and serum creatinine levels. The client reports feeling fatigued and is unable to concentrate during the morning assessments. What action should the nurse take based on these findings?

Correct Answer is D

Explanation

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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?