A nurse on a mental health unit is assisting with the care of a client.

Exhibits

The nurse is continuing to assist with the care of the client. Select the four actions the nurse should take.

Ask the provider for a PRN prescription for restraints.

Administer diazepam when the client exhibits anxiousness.

Place the client in a room near the nurse's station.

Determine if the client is experiencing command hallucinations.

Establish clear limits for expected behaviors.

Answer and Explanation

Correct Answer : B,C,D,E

A. Ask the provider for a PRN prescription for restraints: Restraints should only be used as a last resort when there is an imminent risk of harm to the client or others. In this situation, it is essential to first attempt to manage the client's anxiety and behavior through de-escalation strategies and appropriate interventions.
B. Administer diazepam when the client exhibits anxiousness: Diazepam can help manage anxiety and agitation, which is crucial for the client's safety and comfort. Monitoring for signs of anxiety allows for timely intervention with the prescribed medication.
C. Place the client in a room near the nurse's station: Keeping the client close to the nurse's station allows for increased monitoring and ensures that staff can respond quickly if the client's behavior escalates. This helps maintain safety for both the client and others on the unit.
D. Determine if the client is experiencing command hallucinations: Assessing for command hallucinations is important, especially given the client's recent aggressive behavior. Understanding the presence of such hallucinations can guide the treatment plan and safety measures.
E. Establish clear limits for expected behaviors: Setting clear expectations for behavior helps the client understand acceptable conduct and promotes a safer environment. This can be particularly important for clients with paranoid personality disorder who may struggle with interpersonal relationships.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Antisocial personality disorder: Individuals with antisocial personality disorder typically exhibit a disregard for the rights of others and may engage in manipulative or harmful behaviors. They do not generally display a need for constant reassurance or difficulty making decisions for themselves.
B. Avoidant personality disorder: While individuals with avoidant personality disorder often experience anxiety in social situations and may fear criticism or rejection, they are capable of making decisions. Their behavior is more characterized by avoidance and fear of social interactions rather than a dependency on others for decision-making.
C. Schizoid personality disorder: Individuals with schizoid personality disorder tend to be emotionally detached and have a limited range of emotional expression. They often prefer solitary activities and do not seek out close relationships, which does not align with the need for constant reassurance or decision-making support.
D. Dependent personality disorder: This disorder is characterized by a pervasive and excessive need to be taken care of, leading to submissive and clinging behaviors. Clients with dependent personality disorder often struggle to make decisions independently and require constant reassurance from others, making this the correct identification of the client's manifestations.

A. Biologic parent with schizophrenia B. Biologic grandparent with Fragile X syndrome C. Biologic uncle with Rett syndrome D. Biologic sibling with Down syndrome.

Correct Answer is A

Explanation

A. Biologic parent with schizophrenia: Having a biological parent with schizophrenia significantly increases an individual's risk of developing the disorder due to genetic and hereditary factors. Family studies have shown that the risk of schizophrenia is higher among first-degree relatives, indicating a strong genetic component.
B. Biologic grandparent with fragile X syndrome: Fragile X syndrome is a genetic disorder associated with intellectual disability but is not directly related to the risk of developing schizophrenia. While genetic factors can play a role in various mental health disorders, fragile X syndrome does not specifically indicate an increased risk for schizophrenia.
C. Biologic uncle with Rett syndrome: Rett syndrome is a neurological disorder that primarily affects females and is not associated with an increased risk of schizophrenia. The genetic risk for schizophrenia is more relevant among immediate family members rather than extended relatives like uncles.
D. Biologic sibling with Down syndrome: Down syndrome is a chromosomal disorder caused by an extra copy of chromosome 21 and does not directly increase the risk of developing schizophrenia. While individuals with Down syndrome may experience other mental health issues, the genetic risk for schizophrenia is not associated with this condition.

View Question and Answer

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

A nurse on a mental health unit is assisting with the care of a client. Exhibits The nurse is continuing to assist with the care of the client. Select the four actions the nurse should take.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is unable to make any decisions for themself and needs constant reassurance. The nurse should identify that these are manifestations of which of the following personality disorders?

Correct Answer is D

Explanation

A nurse is reviewing the medical record of a client who recently has been diagnosed with schizophrenia. Which of the following finding is a genetic risk factor associated with the development of schizophrenia?

Correct Answer is A

Explanation

A nurse is assisting in teaching a client who has been newly diagnosed with schizophrenia. Which of the following information should the nurse include?

A nurse is reinforcing teaching with the family of a client who has a new diagnosis of borderline personality disorder about the disorder. Which of the following information should be the nurse's priority?

A nurse is reinforcing discharge teaching with a client who has borderline personality disorder. The client reports being a single parent caring for two toddlers. Which of the following actions should the nurse take?

A nurse is caring for a client who is experiencing delusions, hallucinations, and alterations in speech. Which of the following medications should the nurse anticipate the provider to prescribe?

A nurse is caring for a client who has avoidant personality disorder. Which of the following types of therapy should the nurse anticipate for the client?

A nurse is planning care for several clients. The nurse knows that which of the following findings are common in clients who have dependent personality disorder?

A nurse is meeting with a new client at a substance use disorder clinic. During the meeting, the client states that they have been using cocaine at least once daily for the past 6 months. The nurse is collecting which of the following types of data from the client's account?

A nurse on a mental health unit is assisting with the care of a client.

Exhibits

The nurse is continuing to assist with the care of the client. Select the four actions the nurse should take.