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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale

The shoulder is not the correct fetal presentation in this case. The shoulder presentation, also known as a transverse lie, occurs when the fetus is positioned horizontally in the uterus, and the shoulder is the presenting part. This is not the case in an RSA (Right Sacrum Anterior) position, which indicates a breech presentation.

Choice B rationale

The vertex presentation, also known as a cephalic presentation, occurs when the fetus is positioned head down in the uterus. However, in an RSA position, the fetus is in a breech presentation, not a vertex presentation.

Choice C rationale

The mentum (face) presentation is a rare type of fetal presentation where the neck of the fetus is hyperextended, and the face presents at the cervix. This is not the case in an RSA position, which indicates a breech presentation.

Choice D rationale

In an RSA (Right Sacrum Anterior) position, the fetus is in a breech presentation. This means that the buttocks or feet of the fetus are positioned to enter the birth canal first. Therefore, the nurse should document a breech presentation in the patient’s medical record.

Correct Answer is ["4"]

Explanation

Step 1 is: Identify the dose ordered and the dose available. The dose ordered is 40 mg and the dose available is 10 mg/mL.

Step 2 is: Set up the equation to calculate the volume to administer: (40 mg ÷ 10 mg/mL) = 4 mL.

So, the nurse should administer 4 mL per dose.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing Leopold maneuvers on a patient in labor and determines the fetus is in an RSA position. What fetal presentations should the nurse document in the patient’s medical record?

Correct Answer is D

Explanation

A nurse is preparing to administer furosemide 40 mg IV. Available is furosemide 10 mg/1 mL. How many mL should the nurse administer per dose?

Correct Answer is ["4"]

Explanation

A nurse is conducting a patient’s history and physical examination. Which information should the nurse consider as subjective data?

A nurse is caring for a patient who has a right-sided acoustic neuroma, resulting in impairment of cranial nerves IX andX. Which of the following interventions should the nurse implement?

A nurse is developing a plan of care for a patient who practices Islam. Which of the following actions should the nurse include in the plan?

A nurse is educating a new parent about crib safety.Which statement by the client indicates an understanding of the teaching?

A home health nurse is developing a care plan for a child with hemiplegic cerebral palsy. What is the priority goal for the nurse to include in the care plan?

A nurse is caring for a patient who frequently tries to remove his IV catheter. A family member asks the nurse to apply restraints.What should the nurse’s response be?

A nurse is caring for a patient who is postoperative following abdominal surgery. The nurse discovers a loop of bowel protruding through an opening in the surgical incision. What should the nurse do?

A nurse is providing teaching to a patient who has stable angina and a new prescription for nitroglycerin oral, sustained-release capsules. Which of the following instructions should the nurse give?

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?