A newly admitted patient in an acute manic state has a nursing diagnosis of at risk for injury related to hyperactivity. Which nursing intervention is most appropriate?
Have the patient sit in his room while you review all the rules of the unit.
Reinforce previously learned coping mechanisms to calm the patient down.
Place the patient in a room with another hyperactive patient.
Administer antipsychotic medication as ordered and as needed by the physician.
The Correct Answer is D
Choice A reason: Having the patient sit alone while reviewing rules does not address the immediate risk of injury due to hyperactivity.
Choice B reason: Reinforcing coping mechanisms can help the patient manage hyperactivity and reduce the risk of injury.
Choice C reason: Placing the patient with another hyperactive patient could potentially exacerbate the situation and increase the risk of injury.
Choice D reason: While administering medication may be necessary, it should be done in conjunction with other interventions that address behavior management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason: Reducing saturated fats, which are found primarily in red meat and full-fat dairy products, can lower low-density lipoprotein (LDL) cholesterol — the "bad" cholesterol.
Choice B reason: Avoiding trans fats is crucial as they increase LDL cholesterol and decrease high-density lipoprotein (HDL) cholesterol — the "good" cholesterol.
Choice C reason: Consuming whole grains is beneficial for lowering cholesterol because they contain soluble fiber, which can reduce the absorption of cholesterol into the bloodstream⁶.
Choice D reason: Limiting sugar-sweetened beverages can help reduce cholesterol levels, as excessive sugar intake can lead to weight gain, which is a risk factor for high cholesterol.
Choice E reason: Drinking whole milk is not recommended for cholesterol control as it contains high levels of saturated fat, which can raise cholesterol levels.
Choice F reason: Limiting fruit intake is not necessary for cholesterol control; in fact, fruits can be beneficial due to their fiber content⁶.
Correct Answer is C
Explanation
Choice A reason: Determining a target heart rate is not the primary purpose of an exercise stress electrocardiogram; it is more about observing the heart's function under stress³.
Choice B reason: Identifying the need for more exercise is not the direct outcome of this test; it is used to assess cardiovascular response to stress³.
Choice C reason: The test is designed to show how the heart performs during exercise, which can help diagnose conditions like coronary artery disease³.
Choice D reason: Predicting a heart attack is not the purpose of an exercise stress electrocardiogram; rather, it helps to identify heart conditions that may lead to complications if left untreated³.
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