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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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Provide a tracheostomy tray at the bedside: Incorrect. A tracheostomy tray is not necessary unless the client has a tracheostomy, which is not typically indicated for seizure precautions.

B. Place the client in supine position: Incorrect. The client should be placed on their side to prevent aspiration and promote airway patency during and after a seizure.

C. Insert an IV saline lock: A saline lock is essential in case the client needs emergency medication or fluids, especially during or after a seizure. It allows for quick IV access without continuous infusion.

D. Place a plastic tongue depressor at the client's bedside: Incorrect. A tongue depressor should never be inserted into the mouth during a seizure as it can lead to injury. The priority is to protect the client’s airway and prevent harm.

A. dark red vaginal bleeding, and abdominal pain B. pain a 7 on a scale of 0 to 10 C. "My blood pressure has been high during the pregnancy." D. Uterine hypertonicity with a board-like abdomen, tenderness noted upon palpation of left upper quadrant E. 116/min, minimal variability noted F. bilateral breath sounds clear G. tearful

Correct Answer is ["A","B","C","D","E"]

Explanation

Nurses' Notes

0900:

Client who is at 38 weeks of gestation presents to the antepartum unit with uterine contractions, dark red vaginal bleeding, and abdominal pain that started approximately 45 min prior to arrival. Rates abdominal pain a 7 on a scale of 0 to 10. Client reports, "My blood pressure has been high during the pregnancy."

Home Medications: prenatal multivitamin, methyldopa 250 mg PO twice daily Physical Exam:

General: tearful, anxious

Cardiovascular: S1, S2, no murmur

Respiratory: bilateral breath sounds clear

Abdomen: Uterine hypertonicity with a board-like abdomen, tenderness noted upon palpation of left upper quadrant

FHR: 116/min, minimal variability noted

Rationale:

Dark red vaginal bleeding: This could indicate a serious complication such as placental abruption, which can lead to fetal and maternal distress. Dark red bleeding is often associated with this condition and requires immediate follow-up to determine the source and to prevent further complications.

Uterine hypertonicity with a board-like abdomen: Uterine hypertonicity and a "board-like" abdomen may suggest uterine contractions that are intense or sustained, which could be associated with placental abruption or other serious obstetric complications. This finding needs follow-up to assess for uterine rupture, abruption, or other causes of uterine distress.

Pain score of 7/10: The client's moderate-to-severe pain (rated 7/10) requires follow-up to manage pain and evaluate for its cause. Pain related to placental abruption or other complications may be severe and should be managed appropriately.

FHR of 116/min with minimal variability: A fetal heart rate (FHR) of 116/min is within the normal range, but minimal variability could suggest fetal distress or compromise. Follow-up is needed to continuously monitor fetal well-being and assess for any changes in FHR patterns.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is implementing seizure precautions for a client who has had a tonic-clonic seizure. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is C

Explanation

Correct Answer is ["A","B","C","D","E"]

Explanation

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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.