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
Gently reinserting the bowel back into the patient’s wound is not recommended. This could cause further harm to the patient.
Choice B rationale
Placing the head of the patient’s bed in the flat position is not the best action. This position may not provide the necessary comfort or safety for the patient.
Choice C rationale
Applying moistened sterile gauze to the site is the correct action. This helps to protect the protruding bowel and prevent further contamination until surgical intervention can be performed.
Choice D rationale
Positioning the patient on his left side is not the best action in this situation. It does not directly address the issue of the protruding bowel.
Correct Answer is A
Explanation
Choice A rationale
Engaging in conversation with the patient during wound care can provide emotional support by distracting the patient from the pain and discomfort associated with the procedure. It also helps to build a therapeutic relationship, which is crucial in the healing process.
Choice B rationale
While ensuring the patient’s room is kept tidy by support staff is important for maintaining a clean and safe environment, it does not directly provide emotional support to the patient.
Choice C rationale
Keeping the patient’s family informed about his condition can provide reassurance and reduce anxiety, but it does not directly provide emotional support to the patient.
Choice D rationale
Rotating the nursing staff can provide the patient with varied interactions, but it may not necessarily provide emotional support. Consistency in care providers can often be more beneficial in building trust and rapport.
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