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 D
Explanation
Choice A rationale
After a total laryngectomy, patients may have difficulty swallowing fluids due to changes in the anatomy of the throat.
Choice B rationale
It is not accurate to say that it is no longer possible for the patient to choke on or aspirate food after a total laryngectomy. While the risk of aspiration is reduced because the airway and digestive tract are separated, the patient can still experience choking on food if it is not properly swallowed.
Choice C rationale
Adding a thickener to liquids can help prevent aspiration, but this is typically more relevant for patients with dysphagia or other swallowing disorders, not specifically for patients post- laryngectomy.
Choice D rationale
Tucking the chin when swallowing, also known as the chin-tuck maneuver, can help prevent aspiration by narrowing the entrance to the airway. This can be a useful technique for patients after a laryngectomy.
Correct Answer is B
Explanation
Choice A rationale
Sliced ham with green salad might not be the best choice for a patient with diverticulitis. Ham is a processed meat, which is generally high in fat and can be difficult to digest, potentially irritating the digestive tract. Moreover, a green salad, while generally healthy, can be high in fiber, especially if it includes raw vegetables. During a diverticulitis flare-up, a low-fiber diet is recommended.
Choice B rationale
Grilled chicken breast with white rice is an excellent choice for a patient with diverticulitis. Chicken is a lean protein that is easy to digest. White rice is a low-fiber carbohydrate that is
also easy on the digestive system. This meal is consistent with the dietary recommendations for diverticulitis during the recovery phase, which includes low-fiber foods.
Choice C rationale
A turkey sandwich with celery sticks might not be suitable for a patient with diverticulitis. While turkey is a lean protein, celery sticks are high in fiber and can be difficult to digest, potentially irritating the digestive tract.
Choice D rationale
Pork tenderloin with green peas might not be the best choice for a patient with diverticulitis. Although pork tenderloin is a lean meat, green peas are high in fiber and can be difficult to digest, potentially irritating the digestive tract.
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