A client with a diagnosis of schizophrenia sits in the day room and fails to interact with the staff or peers. Which intervention is best for the nurse to implement with this client?

Give the client a schedule of planned daily activities.

Engage the client in a game of cards.

Encourage the client to have lunch off the unit.

Complete an assessment of social support.

Answer and Explanation

The Correct Answer is A

A)   Correct- this can help them structure their time, reduce boredom and anxiety, and increase their sense of control and achievement. This can also foster social interaction and engagement with the staff and peers. A schedule of planned daily activities is consistent with the principles of psychosocial rehabilitation, which is an evidence-based approach for people with schizophrenia.
B)   Incorrect- this may be too challenging or stressful for the client, especially if they have cognitive impairments or negative symptoms.
C)   Incorrect- may expose them to unfamiliar or unpredictable situations that could trigger or worsen their psychotic symptoms.
D)   Incorrect- it is not an intervention that directly addresses the client's current problem of social isolation.

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Correct Answer is D

Explanation

A.While pain management is important, it is not the most critical intervention compared to monitoring for bleeding, which can be life-threatening.

B.Teaching the client how to use incentive spirometry is important for improving lung function and preventing complications like atelectasis. However, in the context of a pulmonary embolism (PE), the immediate priority is to monitor for signs of increased bleeding due to the anticoagulant or thrombolytic therapy often used to treat PE. This is crucial to prevent potentially life-threatening complications.

C.Confusion and restlessness could indicate hypoxia, which is important to monitor in a PE patient. However, the immediate risk of bleeding due to anticoagulation therapy takes precedence.

D.Patients with a pulmonary embolism are typically treated with thrombolytic or anticoagulant therapy to prevent further clot formation and to help dissolve the existing clot. Anticoagulants significantly increase the risk of bleeding, making it crucial to monitor for signs of increased bleeding as a priority in the plan of care.

A. Encourage the use of ice on the areola. B. Teach about the use of a breast pump. C. Offer supplemental formula feedings. D. Recommend using a breast shield.

Correct Answer is B

Explanation

The correct answer is Choice B.

Choice A rationale: Ice application induces vasoconstriction, which reduces swelling but does not evert inverted nipples. This action does not address the primary issue of nipple inversion preventing adequate latch.

Choice B rationale: Breast pump use creates negative pressure, drawing out the nipple. This eversion facilitates latching by providing a more prominent nipple for the infant's oral cavity to grasp effectively.

Choice C rationale: Supplemental formula feedings provide nutrition, but do not resolve the latching difficulty caused by inverted nipples. This can interfere with the establishment of the mother's milk supply.

Choice D rationale: Breast shields can aid latching, but they are most effective when used in conjunction with nipple eversion techniques. They do not directly address the underlying problem of inverted nipples.

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A client with a diagnosis of schizophrenia sits in the day room and fails to interact with the staff or peers. Which intervention is best for the nurse to implement with this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After having a pulmonary angiogram, a client is diagnosed with a pulmonary embolism (PE). Which intervention is most important for the nurse to include in the client's plan of care?

Correct Answer is D

Explanation

A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast. The nurse determines that the client's nipples are inverted. Which action should the nurse implement?

Correct Answer is B

Explanation

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behavior(s) indicate the client understands how to maintain balance safely? (Select all that apply.)

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After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?