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 A
Explanation
Choice A rationale
The statement “Our car seat is an infant model and is anchored in the car” indicates a correct understanding of car seat safety. Infant car seats are specifically designed to protect infants during a collision. They are rear-facing seats, which is the safest position for an infant because it provides the most support for the infant’s head, neck, and spine. Anchoring the car seat in the car is crucial as it ensures the seat stays in place during a collision.
Choice B rationale
The statement “The car seat is rear-facing in the front passenger seat” is incorrect. It is not safe to place a rear-facing car seat in the front passenger seat of a vehicle. In the event of a collision, an airbag can deploy and hit the car seat, causing serious injury to the infant.
Choice C rationale
The statement “I can fit my hand between the baby and the car seat harness” is incorrect. The harness of a car seat should be snug against the baby’s body. If you can fit your hand between the baby and the harness, it means the harness is too loose, which can be dangerous in the event of a collision.
Choice D rationale
The statement “Our car seat is front-facing in the back seat” is incorrect. Infants should always be in a rear-facing car seat until they reach the highest weight or height allowed by their car safety seat’s manufacturer.
Correct Answer is A
Explanation
Choice A rationale
Hyperventilation is a potential treatment for brain herniation. Hyperventilation causes a decrease in carbon dioxide levels in the blood, leading to vasoconstriction of the cerebral blood vessels. This reduces cerebral blood flow and decreases intracranial pressure, which can help in the management of brain herniation.
Choice B rationale
Decreasing sedation is not typically a treatment for brain herniation. Sedation can be used in the management of increased intracranial pressure, but it is not a direct treatment for brain herniation.
Choice C rationale
Reducing the temperature in the room is not a direct treatment for brain herniation. While temperature control is important in the overall management of a patient with brain injury, it does not directly treat brain herniation.
Choice D rationale
Lowering blood pressure is not a direct treatment for brain herniation. While maintaining optimal blood pressure is important in the management of brain injury, aggressive lowering of blood pressure is not typically done as it could compromise cerebral perfusion.
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