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
Engaging in conversation with the patient during wound care can provide emotional support by distracting the patient from the pain and discomfort associated with the procedure. It also helps to build a therapeutic relationship, which is crucial in the healing process.
Choice B rationale
While ensuring the patient’s room is kept tidy by support staff is important for maintaining a clean and safe environment, it does not directly provide emotional support to the patient.
Choice C rationale
Keeping the patient’s family informed about his condition can provide reassurance and reduce anxiety, but it does not directly provide emotional support to the patient.
Choice D rationale
Rotating the nursing staff can provide the patient with varied interactions, but it may not necessarily provide emotional support. Consistency in care providers can often be more beneficial in building trust and rapport.
Correct Answer is ["A","C","D","E"]
Explanation
Smoking, Diabetes, Atherosclerosis, and Weak pedal pulses.
Factors that contribute to poor circulation to the limb include:
- Smoking: It can cause constriction and damage to the blood vessels, leading to poor circulation.
- Diabetes: High blood sugar levels can damage blood vessels and nerves, leading to poor circulation.
- Atherosclerosis: This is a condition where plaque builds up in the arteries, narrowing them and reducing blood flow.
- Weak pedal pulses: This can be a sign of reduced blood flow to the lower extremities. A sodium-restricted diet (Choice B) is not typically associated with poor circulation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.