A nurse is caring for a client on a psychiatric unit.

Exhibits

For each potential action, click to specify if the action is indicated or contraindicated for the client.

Ask the client about the content of their hallucinations.

Instruct the client on expected hygiene practices.

Allow the client to watch TV at a high volume.

Assess the client for suicidal ideation.

Place the client in a room near the activity

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}

Potential action	Indicated	Contraindicated
Ask the client about the content of their hallucinations.	✓
Instruct the client on expected hygiene practices.	✓
Allow the client to watch TV at a high volume.		✓
Assess the client for suicidal ideation.	✓
Place the client in a room near the activity		✓

Rationale

Ask the client about the content of their hallucinations: Indicated
- Understanding the content of hallucinations can help in assessing the severity and nature of the client's condition, and in planning appropriate interventions.
Instruct the client on expected hygiene practices: Indicated
- Encouraging and educating the client about personal hygiene is important for their overall well-being and social interactions.
Allow the client to watch TV at a high volume: Contraindicated
- High volume and excessive stimulation can exacerbate symptoms of schizophrenia, such as hallucinations and agitation.
Assess the client for suicidal ideation: Indicated
- Regular assessment for suicidal thoughts is crucial, even if the client initially denies them, as their mental state can change.
Place the client in a room near the activity: Contraindicated
- A quieter environment is generally more beneficial for clients with schizophrenia to reduce overstimulation and stress.

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Correct Answer is D

Explanation

A. "Keep your feet together to provide a tight base of support": Incorrect. Keeping feet together reduces stability; a wide base of support is recommended.

B. "Keep objects away from your center of gravity while lifting": Incorrect. Objects should be kept close to the center of gravity to reduce strain.

C. "Bend at the waist when lifting objects from the floor": Incorrect. Bending at the knees, not the waist, is the correct technique to prevent back injury.

D. "Tighten abdominal muscles to improve balance": Tightening the abdominal muscles provides core stability and reduces the risk of injury when lifting.

A. Painful, tender breast B. Foul-smelling lochia C. Temperature D. Chills

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Explanation

Assessment Findings Consistent with Mastitis or Endometritis

Painful, tender breast: Mastitis
- Mastitis often presents with breast pain, tenderness, and redness.
Foul-smelling lochia: Endometritis
- Endometritis can cause foul-smelling vaginal discharge or lochia.
Temperature: Both Mastitis and Endometritis
- Both conditions can cause fever.
Chills: Both Mastitis and Endometritis
- Chills can be a symptom of both mastitis and endometritis

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not.. I found the title to the car today, signed over to me.
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom. Client reports not wanting to eat anymore. Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

A nurse is caring for a client on a psychiatric unit. Exhibits For each potential action, click to specify if the action is indicated or contraindicated for the client.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An occupational health nurse is providing teaching to a group of factory workers about proper lifting techniques. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A nurse is caring for a client who is 4 days postpartum following a cesarean birth. Exhibits For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Explanation

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A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states that he needs to have a bowel movement, and the nurse offers a bed pan. The client states, "I've always used the bathroom." Which of the following responses should the nurse make?

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A nurse is caring for a client on a psychiatric unit.

Exhibits

For each potential action, click to specify if the action is indicated or contraindicated for the client.