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 ["B","C"]
Explanation
Choice A rationale
Insulin glargine does not last for 3 to 6 hours. It is a long-acting insulin that has a duration of action up to 24 hours.
Choice B rationale
This is correct. Insulin glargine lasts for 18 to 24 hours. It is a long-acting insulin that provides a base level of insulin that keeps working for 24 hours or longer.
Choice C rationale
This is also correct. Insulin glargine lasts for 16 to 24 hours. It is a long-acting insulin that provides a base level of insulin that keeps working for 24 hours or longer.
Choice D rationale
Insulin glargine does not last for 6 to 10 hours. It is a long-acting insulin that has a duration of action up to 24 hours.
Correct Answer is C
Explanation
An abnormal absolute neutrophil count in a preschooler should be reported to the healthcare provider immediately. Neutrophils are a type of white blood cell that play a key role in the body’s immune response. An abnormal count could indicate an infection, inflammation, or other serious health conditions.
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