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.

Answer and Explanation

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.

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Correct Answer is ["B","D"]

Explanation

Choice A reason: Taking Lasix in the morning is appropriate to avoid nocturia and sleep disturbances.

Choice B reason: Patients should be cautious with fluid intake when taking Lasix to avoid fluid overload, especially in heart failure.

Choice C reason: Counting the radial pulse is not directly related to Lasix administration but is a good practice for monitoring heart rate.

Choice D reason: Lasix should not be taken with each meal; it is usually taken once daily unless otherwise prescribed.

Choice E reason: Eating a banana daily is recommended to replenish potassium that may be lost due to the diuretic effect of Lasix.

A. Discourage the client from expressing anger. B. Reinforce how to use assertive communication techniques. C. Set short-term and long-term goals for the client. D. Schedule the client's daily self-care activities.

Correct Answer is B

Explanation

Choice A reason: Discouraging the client from expressing anger is not therapeutic and can inhibit emotional expression, which is important in managing depression.

Choice B reason: Reinforcing assertive communication techniques is beneficial as it helps clients express themselves in a healthy way, which is a key aspect of depression management.

Choice C reason: Setting goals is important, but it should be done collaboratively with the client to empower them and ensure the goals are realistic and achievable.

Choice D reason: Scheduling daily self-care activities is helpful, but teaching the client how to manage their own schedule can promote independence and self-efficacy.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","D"]

Explanation

A nurse is reviewing the plan of care for a client who has depression. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A patient asks the nurse what a diagnosis of heart failure means. Which of the following is the nurse's best response?

A nurse is collecting data from an older adult client who has been taking digoxin for the past several months. For which of the following manifestations of digoxin toxicity should the nurse monitor?

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