A nurse is preparing to admit a client who has bacterial meningitis. Which of the following items should the nurse place in the client's room?

Oral imaging device

Seizure pads

Sterile gloves

Tongue blade

Answer and Explanation

The Correct Answer is B

A.   An oral imaging device is not typically needed for the care of a client with bacterial meningitis. This device is used for examining the oral cavity and throat and is not specific to the care of meningitis.
B.   Seizure pads should be placed in the client's room because bacterial meningitis can lead to seizures as a complication. Seizure pads are placed under the client during a seizure to protect them from injury due to falls or thrashing movements.
C.   Sterile gloves may be necessary for certain procedures or when providing direct care to the client with bacterial meningitis, but they are not specific to the care of this condition. They should be readily available in the room for use as needed.
D.   A tongue blade is not necessary for the care of a client with bacterial meningitis. Tongue blades are used for oral examination and to depress the tongue during certain medical procedures, but they are not specific to the care of meningitis.

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Correct Answer is A

Explanation

A. Documenting in the client's medical record every 15 minutes is essential to monitor the client's status, including physical and psychological well-being, while in restraints. Accurate documentation ensures that any changes or responses to the intervention are recorded and communicated to other healthcare providers.
B. Offering toileting to the client every 4 hours may be necessary depending on the client's

individual needs, but it does not address the immediate need for monitoring the client's safety and well-being while restrained.
C. Removing the restraint when the client falls asleep is not appropriate without a healthcare provider's order. Restraints should only be removed based on a specific criteria set forth by
institutional policies or as directed by the healthcare provider.

D. Requesting an as-needed prescription for restraints is not appropriate. Restraints should only be used when necessary to ensure the safety of the client or others, and their use should be based on a healthcare provider's assessment and orders.

A. Depersonalization B. Hallucination C. Illusion D. Derealization

Correct Answer is B

Explanation

A. Depersonalization is a feeling of detachment from oneself or feeling like one's thoughts, feelings, and actions are not their own. It does not involve perceptual disturbances such as hearing voices.
B. Hallucination is a sensory perception that occurs in the absence of external stimuli. Auditory hallucinations involve hearing voices or sounds that others do not hear, as described by the client in this scenario.
C. Illusion is a misinterpretation of a sensory stimulus that is actually present in the environment. It involves a distortion or misperception of sensory information, not the perception of something that is not there, as in the case of hallucinations.
D. Derealization is a feeling of unreality or detachment from one's surroundings. It involves a distortion in the perception of the external world rather than sensory experiences such as hearing voices.

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A nurse is preparing to admit a client who has bacterial meningitis. Which of the following items should the nurse place in the client's room?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is in mechanical restraints after becoming violent with a staff member. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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