A nurse is caring for a client.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

Potential Condition The client is most likely experiencing b. Antisocial personality disorder. This is suggested by the client’s lack of remorse, impulsivity, deceitfulness, and aggressive behavior when denied something she wants.

Actions to Take To address this condition, the nurse should:

a. Assess history of criminal behavior: This can provide insight into the severity and pattern of the client’s antisocial behavior.
e. Establish clear and realistic boundaries regarding behavior: This can help manage the client’s impulsivity and aggressive behavior.

Parameters to Monitor To assess the client’s progress, the nurse should monitor:

c. Aggressive and violent behavior: Any reduction in these behaviors can indicate improvement.
e. Deceitfulness: A decrease in deceitful behavior can also signal progress.

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 C

Explanation

Choice A Reason:
Documenting the client's behavior every 60 minutes is important for monitoring the client's condition and ensuring their safety. However, it is not the most immediate action required following the initiation of seclusion. Continuous documentation helps in assessing the effectiveness of the intervention and making necessary adjustments to the care plan.

Choice B Reason:
Keeping the client in seclusion for no longer than 6 hours is a guideline to prevent prolonged isolation, which can have negative psychological effects. However, this is not the first action the nurse should take. The duration of seclusion should be based on the client's behavior and the clinical judgment of the healthcare team.

Choice C Reason:
Obtaining a prescription for seclusion within 30 minutes is crucial because it ensures that the use of seclusion is medically justified and legally documented. This action aligns with regulatory requirements and best practices in mental health care. It ensures that the intervention is necessary and that the client's rights are protected.

Choice D Reason:
Monitoring the client's vital signs every 4 hours is essential for assessing the client's physical health and detecting any adverse effects of seclusion. However, like documenting behavior, it is not the most immediate action required. Regular monitoring helps in ensuring the client's safety and well-being during the period of seclusion.

A. Discuss adverse effects of antianxiety medications with a client who has an anxiety disorder. B. Participate in solitary activities with a client who has mania. C. Explain the benefits of light therapy to a client who has a depressive disorder. D. Witness an informed consent for a client who is scheduled for electroconvulsive therapy.

Correct Answer is B

Explanation

Choice A reason:
The statement "Discuss adverse effects of antianxiety medications with a client who has an anxiety disorder" is not appropriate for delegation to assistive personnel. Discussing medication effects requires specialized knowledge and the ability to provide detailed explanations and answer questions, which falls within the scope of practice for licensed nurses or healthcare providers.

Choice B reason:
The statement "Participate in solitary activities with a client who has mania" is the correct response. Assistive personnel can engage clients in activities that do not require specialized medical knowledge or judgment. Participating in solitary activities can help manage the client's symptoms and provide therapeutic engagement.

Choice C reason:
The statement "Explain the benefits of light therapy to a client who has a depressive disorder" is not suitable for delegation to assistive personnel. Explaining treatment benefits and answering related questions requires a deeper understanding of the therapy and its implications, which is within the scope of practice for licensed nurses or healthcare providers.

Choice D reason:
The statement "Witness an informed consent for a client who is scheduled for electroconvulsive therapy" is not appropriate for delegation to assistive personnel. Witnessing informed consent involves ensuring that the client fully understands the procedure, its risks, and benefits, which requires professional judgment and is typically performed by licensed nurses or healthcare providers.

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

Neurologic:	Fatigue after being awake a few hours, feels “restless”. Difficulty concentrating on work and other activities. Difficulty falling asleep and wakes up “after a few hours". Worried about work and family needs.
Musculoskeletal:	Reports muscles feel tight and achy. Ambulates without assistance. Moves all four extremities independently.
Gastrointestinal:	Bowel sounds distant, present x four quadrants. Abdomen soft and nondistended, bladder slightly palpable.
Cardiovascular:	Apical 92/min and regular; peripheral pulses present bilaterally. Absence of lower extremity edema.
Respiratory:	Breath sounds present bilaterally. Occasional dry cough.

A nurse is caring for a client. Exhibits Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute care mental health facility is caring for a client who has been placed in seclusion following an acute violent episode. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is planning to delegate client care for several clients in a mental health facility. Which of the following tasks should the nurse delegate to an assistive personnel?

Correct Answer is B

Explanation

A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take a prescribed oral antianxiety medication. Which of the following actions should the nurse take?

A nurse is receiving a change-of-shift report about a group of assigned clients at a mental health facility. Which of the following clients should the nurse assess for risks related to sensory impairments?

A nurse is caring for a client who is experiencing active auditory hallucinations. Which of the following actions should the nurse take?

A nurse is planning care for a client who has complicated grieving following the death of her child. Which of the following interventions should the nurse identify as the priority?

A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply)