A nurse is caring for a client who has agreed to a verbal safety contract following a self-mutilation attempt. Which of the following behaviors indicates that the contract has been effective?

The client goes to their room alone when they feel overwhelmed.

The client displaces their feelings of self-harm until they talk to the provider.

The client suppresses their feelings when they are angry.

The client notifies the nurse when they want to harm themselves.

Answer and Explanation

The Correct Answer is D

Choice A reason: Going to their room alone when feeling overwhelmed may indicate that the client is trying to manage their emotions, but it does not directly address the effectiveness of the safety contract. The goal of the contract is to ensure that the client seeks help and communicates their feelings of self-harm to a healthcare provider.

Choice B reason: Displacing feelings of self-harm until talking to the provider is not a clear indication of the contract's effectiveness. The client may still be at risk of self-harm if they do not have immediate access to the provider. The safety contract aims to encourage the client to seek help and communicate their feelings promptly.

Choice C reason: Suppressing feelings when angry is not a healthy coping mechanism and does not indicate the effectiveness of the safety contract. The contract should promote open communication and seeking help rather than suppressing emotions, which can lead to further distress and potential self-harm.

Choice D reason: Notifying the nurse when they want to harm themselves is a clear indication that the safety contract has been effective. The client is following the agreed-upon plan to seek help and communicate their feelings of self-harm, which is the primary goal of the safety contract. This behavior demonstrates that the client is taking steps to ensure their safety and seeking support from healthcare providers.

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Correct Answer is C

Explanation

Choice A reason: While a stimulating environment can be beneficial in engaging a client with Alzheimer's disease, it is not directly related to assisting with activities of daily living (ADLs). The goal is to create an environment that simplifies tasks and reduces confusion, which might be better achieved through other methods.

Choice B reason: Offering several choices for daily activities and meals can overwhelm a client with Alzheimer's disease. Simplifying choices and providing clear, structured routines are more effective strategies. Too many options can lead to confusion and difficulty in decision-making for these clients.

Choice C reason: Providing clothing with elastic or fastening tape simplifies the process of dressing and undressing, making it easier for the client to maintain independence in ADLs. This type of clothing can reduce frustration and promote a sense of autonomy, which is crucial for clients with Alzheimer's disease.

Choice D reason: Keeping the bedroom dark while the client is sleeping can promote better sleep, but it does not directly assist with performing ADLs. Ensuring the client has adequate lighting and a safe environment during waking hours is more relevant to supporting their ability to perform daily activities.

A. Hypoactive bowel sounds in all four quadrants. B. Client report of dry mouth. C. Constant opening and closing of mouth. D. Client report of photosensitivity.

Correct Answer is C

Explanation

Choice A reason: Hypoactive bowel sounds can indicate a variety of gastrointestinal issues, but they are not typically associated with haloperidol use. While it is important to monitor bowel sounds, it is not the priority in this context.

Choice B reason: Dry mouth is a common side effect of many medications, including haloperidol. While it can be uncomfortable for the client, it is not usually a serious concern and can be managed with hydration and other supportive measures.

Choice C reason: Constant opening and closing of the mouth, also known as tardive dyskinesia, is a serious side effect of haloperidol and other antipsychotic medications. This condition involves involuntary muscle movements and can be irreversible. It is crucial to report this finding to the provider immediately for assessment and potential adjustment of the medication regimen.

Choice D reason: Photosensitivity is not a common side effect of haloperidol. While it is important to monitor for any new or unusual symptoms, photosensitivity is not typically associated with this medication.

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A nurse is caring for a client who has agreed to a verbal safety contract following a self-mutilation attempt. Which of the following behaviors indicates that the contract has been effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a client who has Alzheimer's disease. Which of the following actions should the nurse recommend implementing to assist the client with performing ADLs?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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