A nurse is admitting a patient exhibiting manic behavior.
The patient reports recent personal stressors, including the loss of her mother and a divorce. What should be the nurse’s priority action?
Encourage self-care.
Assist the patient in identifying coping behaviors.
Prevent self-directed violence.
Identify support systems.
The Correct Answer is C
Choice A rationale
Encouraging self-care is important, but it may not be the immediate priority if the patient is exhibiting manic behavior and has recently experienced significant personal stressors.
Choice B rationale
Assisting the patient in identifying coping behaviors is a key part of treatment, but it may not be the immediate priority if the patient is at risk of self-harm.
Choice C rationale
Preventing self-directed violence is the priority action. Patients exhibiting manic behavior may have impaired judgment and impulse control, putting them at risk of self-harm.
Choice D rationale
Identifying support systems is important, but it may not be the immediate priority if the patient is at risk of self-harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Performing passive range of motion exercises on the right leg in Buck’s traction may not be appropriate. These exercises involve moving the joint without the patient’s muscles doing the work, which could disrupt the traction.
Choice B rationale
Isometric exercises involve contracting the muscles without moving the joints. While these exercises can be beneficial for maintaining muscle strength, they may not promote mobility.
Choice C rationale
Performing active range-of-motion exercises on the left leg can help promote mobility. These exercises involve the patient moving the joint through its full range of motion, which can help maintain joint flexibility and muscle strength.
Choice D rationale
Log rolling the patient every 2 hours may not be appropriate for a patient in Buck’s traction. This technique involves turning the patient as a unit to prevent twisting and protect the spine, which could disrupt the traction.
Correct Answer is D
Explanation
Choice A rationale
Stopping aspirin a week before surgery is generally recommended to reduce the risk of bleeding. Aspirin can inhibit platelet aggregation and prolong bleeding time.
Choice B rationale
Taking prescribed blood pressure medication with a sip of water on the day of surgery is usually allowed. However, this can depend on the specific medication and the patient’s health status.
Choice C rationale
Not wearing contact lenses on the day of surgery is a standard preoperative instruction. This is because contact lenses can interfere with anesthesia administration and potentially cause injury to the eyes.
Choice D rationale
A recent cough and runny nose could indicate a respiratory infection. This could potentially increase the risk of complications during surgery and may need to be evaluated further. OK. Let’s go through these questions one by one:
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