A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make?

"I will call the doctor and get a prescription."

"I will cover the catheter so he cannot see it."

"I will provide more stimulation in his environment."

"Let's wait until tonight to see if he continues this behavior."

Answer and Explanation

The Correct Answer is B

Choice A reason : While consulting with the healthcare provider is important, immediate action is necessary to prevent harm. Waiting for a prescription may delay intervention.

Choice B reason : When a patient frequently attempts to remove their intravenous (IV) catheter, it's essential to address the behavior promptly to prevent potential complications such as catheter dislodgement, infection, or injury. The most appropriate initial response is to cover the catheter to reduce the patient's awareness and access, thereby decreasing the likelihood of tampering.

Choice C reason : Providing more stimulation could be counterproductive if the client is already agitated or confused. The nurse should assess the client's needs and environment to determine the appropriate level of stimulation.

Choice D reason : Waiting without taking action is not advisable as the client may harm themselves by removing the IV catheter. Immediate intervention is required to ensure the client's safety.

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Correct Answer is C

Explanation

Choice A reason: Obsessive-Compulsive Disorder (OCD) is characterized by persistent, unwanted thoughts (obsessions) and behaviors (compulsions) that the individual feels the urge to repeat over and over. While OCD is a separate condition that can co-occur with many disorders, it is not commonly associated as a comorbidity with histrionic personality disorder⁴⁵.

Choice B reason: Schizophrenia is a severe mental disorder that affects how a person thinks, feels, and behaves. It is not typically associated with histrionic personality disorder, which is characterized by excessive emotionality and attention-seeking behaviors⁴⁵.

Choice C reason: Generalized Anxiety Disorder (GAD) is a common comorbidity with histrionic personality disorder. Individuals with histrionic personality disorder may experience high levels of anxiety, which can manifest as GAD. This anxiety often relates to fears of rejection or not being the center of attention⁴⁵.

Choice D reason: Anorexia Nervosa is an eating disorder characterized by an abnormally low body weight, intense fear of gaining weight, and a distorted perception of body weight. It is more commonly associated with other conditions, such as obsessive-compulsive and avoidant personality disorders, rather than histrionic personality disorder⁴⁵.

A. Heat intolerance B. Facial edema C. Tachycardia D. Diarrhea

Correct Answer is B

Explanation

Choice A reason : Heat intolerance is not a symptom associated with myxedema coma. Instead, patients with myxedema coma typically present with cold intolerance due to decreased metabolic rate and reduced heat production as a result of hypothyroidism¹.

Choice B reason : Facial edema, particularly around the eyes, is a characteristic finding in myxedema coma. This condition results from severe hypothyroidism, which can cause mucopolysaccharide deposition in the skin, leading to non-pitting edema¹.

Choice C reason : Tachycardia is not expected in myxedema coma; rather, bradycardia is more common due to the reduced metabolic demands of the body in the hypothyroid state¹.

Choice D reason : Diarrhea is not typically a symptom of myxedema coma. Patients are more likely to experience constipation due to slowed gastrointestinal motility in the context of hypothyroidism¹.

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A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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