A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the practical nurse (PN) implement first?
Explain the daily schedule of unit activities.
Review client rights of hospitalization.
Offer the client an as-needed (PRN) medication.
Describe the functions of the practical nurse (PN).
The Correct Answer is D
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is the finding that the PN should document as evidence that the amount of insulin is inadequate for the client with type 1 diabetes mellitus. Consecutive evening serum glucose greater than 260 mg/dL indicates hyperglycemia, which means that the client's blood sugar is too high and not well controlled by the insulin dose. The PN should report this finding to the healthcare provider and expect a possible adjustment in the insulin regimen.
Correct Answer is ["A","B","C","E","H"]
Explanation
To identify the potential source of the client's new-onset confusion and decreased appetite, the nurse can use the following assessment techniques:
- Ask to see the client's list of home medications: This can help identify any medications that may contribute to confusion or appetite changes.
- Determine if the client has recently lost a loved one: Emotional distress, such as grief from a recent loss, can contribute to changes in mental status and appetite.
- Measure the client's vital signs: Vital signs can provide important information about the client's overall health status and help identify any abnormalities that may be contributing to the symptoms.
- Perform a 12-lead electrocardiogram: This can help assess the client's cardiac function and detect any cardiac-related causes for the symptoms.
- Ask about the client's last bowel movement: Changes in bowel habits can sometimes be indicative of underlying issues affecting appetite and overall health.
- Measure the client's abdominal circumference: This can help assess for any abdominal distension or changes that may be related to the client's symptoms.
Collecting a sputum and urine culture and sensitivities and having the client ambulate across the room are not directly related to identifying the potential source of confusion and decreased appetite in this case.
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