A nurse in an inpatient mental health unit is planning care for a client who is in restraints. Which of the following findings should indicate to the nurse that the client is ready to reintegrate into the unit?
The client eats all of the food provided for each of her meals.
The client requests to use the bathroom.
The client follows directions.
The client's vital signs are within the expected reference range.
The Correct Answer is B
A. Eating all of the food provided for each of her meals may indicate that the client is physically stable, but it doesn't directly reflect the client's readiness to reintegrate socially or behaviorally into the unit.
B. The client requests to use the bathroom is the most appropriate indicator of readiness to reintegrate. This demonstrates that the client is regaining some level of control over their environment and is able to communicate basic needs. It's a sign of behavioral and emotional readiness to resume participation in regular activities.
C. Following directions is important, but it alone does not necessarily indicate emotional or behavioral readiness to reintegrate. The client may still need further assessment of their emotional state and impulse control before being reintegrated.
D. While vital signs being within the expected reference range is important for physical stability, it does not provide enough information regarding the client's emotional and behavioral readiness for reintegration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Discolored urine is not a known or serious adverse effect of buspirone and typically does not warrant reporting.
B. Decreased appetite can occur but is usually mild and not typically a reason to stop the medication.
C. Hallucinations are not a common side effect of buspirone and may indicate a serious reaction or an underlying worsening of the mental health condition. This should be reported to the provider immediately.
D. Sweating can occur with buspirone but is generally considered a mild and non-serious side effect.
Correct Answer is D
Explanation
A. Clang associations involve the use of words that are similar in sound but have no meaningful connection This does not apply to the word "flakalas."
B. Echolalia is the repetition of words or phrases that the client has heard, often without understanding or processing their meaning. The client is not repeating words heard from others in this situation.
C. Word salad is a disorganized speech pattern where words are jumbled together in a random and incoherent way. The word "flakalas" is not part of such disorganized speech.
D. Neologism refers to the creation of new, made-up words that have no meaning to others but hold significance for the person speaking. The client’s use of the word "flakalas" is an example of a neologism, as it appears to be a newly created word without a standard meaning.
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