A nurse is caring for a patient who attacked a friend and is now admitted to the psychiatric unit. Which of the following actions should the nurse take first?
Establish a patient relationship.
Explore the truth of the patient’s statements.
Set behavioral limits for the patient.
Explain to the patient that the behavior was unacceptable.
The Correct Answer is C
Choice A rationale
Establishing a patient relationship is important, but it’s not the first action the nurse should take. The nurse must first ensure safety for all involved.
Choice B rationale
Exploring the truth of the patient’s statements is a part of the therapeutic process, but it’s not the first step. The immediate concern should be to ensure safety.
Choice C rationale
Setting behavioral limits for the patient is the first action the nurse should take. This is crucial in managing a patient who has shown aggressive behavior. It helps to establish boundaries and expectations, which can prevent further aggressive incidents.
Choice D rationale
While it’s important to explain to the patient that the behavior was unacceptable, this is not the first action. The immediate priority is to ensure safety by setting behavioral limits.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
As an advocate, the nurse acts to protect the patient’s rights and helps them to speak for themselves. This includes supporting the patient’s decisions, even when these decisions might not be in line with the nurse’s personal beliefs.
Choice B rationale
As a manager, the nurse coordinates activities of members of the nursing staff in delivering nursing care, and oversight ensures that care is safe, effective, and patient-centered.
Choice C rationale
As a caregiver, the nurse assists patients with meeting their physical, psychological, and developmental needs. This role involves direct patient care activities.
Choice D rationale
As an educator, the nurse works to enhance patients’ knowledge about their health and care, promoting health behaviors and self-care skills.
Correct Answer is B
Explanation
Choice A rationale
Petechiae, or small red or purple spots on the skin caused by minor bleeding from broken capillary blood vessels, are an objective finding. They can be seen and evaluated by the nurse during a physical examination.
Choice B rationale
Nausea is a subjective symptom. It is something the patient experiences and reports, but it cannot be directly observed or measured by the nurse.
Choice C rationale
Cyanosis, or bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood, is an objective finding. It can be observed by the nurse during a physical examination.
Choice D rationale
Fever is an objective finding. It can be measured by the nurse using a thermometer.
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