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","D"]
Explanation
Choice A rationale
In ARDS, impaired carbon dioxide elimination due to shunting can occur. Shunting refers to the diversion of blood from areas of the lung that are ventilated to areas that are not, leading to impaired gas exchange.
Choice B rationale
Decreased pulmonary arterial pressure due to ventilation-perfusion (V/Q) mismatch is not a typical finding in ARDS3.
Choice C rationale
Hypoxemia due to dead space is not a typical finding in ARDS. Dead space refers to areas of the lung that are ventilated but not perfused.
Choice D rationale
Decreased pulmonary compliance due to stiffness is a typical finding in ARDS. The lungs become stiff and less compliant due to the accumulation of fluid and inflammatory cells in the alveoli and interstitial space.
Correct Answer is D
Explanation
Choice A rationale
The shoulder is not the correct fetal presentation in this case. The shoulder presentation, also known as a transverse lie, occurs when the fetus is positioned horizontally in the uterus, and the shoulder is the presenting part. This is not the case in an RSA (Right Sacrum Anterior) position, which indicates a breech presentation.
Choice B rationale
The vertex presentation, also known as a cephalic presentation, occurs when the fetus is positioned head down in the uterus. However, in an RSA position, the fetus is in a breech presentation, not a vertex presentation.
Choice C rationale
The mentum (face) presentation is a rare type of fetal presentation where the neck of the fetus is hyperextended, and the face presents at the cervix. This is not the case in an RSA position, which indicates a breech presentation.
Choice D rationale
In an RSA (Right Sacrum Anterior) position, the fetus is in a breech presentation. This means that the buttocks or feet of the fetus are positioned to enter the birth canal first. Therefore, the nurse should document a breech presentation in the patient’s medical record.
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