A nurse on a mental health unit is caring for a newly admitted client.

Exhibits

The nurse is continuing to care for the client. Which of the following actions should the nurse take?(Select All that Apply.)

Gently place a hand on the client's arm during conversation.

Employ active listening skills when communicating with the client.

Administer an anxiolytic medication to the client.

Explain the expected behavioral limits to the client.

Assist the client to identify the source of anger.

Answer and Explanation

Correct Answer : B,C,D,E

A. Gently place a hand on the client's arm during conversation
Avoid touching an anxious or potentially aggressive client-may escalate agitation.

B. Employ active listening skills
Validates feelings and promotes therapeutic communication.

C. Administer an anxiolytic medication
Client is showing signs of withdrawal and agitation-medication may be indicated.

D. Explain behavioral limits
Setting limits provides structure and promotes safety.

E. Assist in identifying source of anger
Supports emotional processing and de-escalation.

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Correct Answer is D

Explanation

A. Coping ability
This is important but not a priority immediately post-op.

B. Surgical dressing
Should be assessed, but airway and tube patency are more urgent.

C. Bowel sounds
Not a priority immediately post-op; expected to be decreased due to anesthesia.

D. Patency of NG tube
Ensures gastric decompression, prevents aspiration, and supports post-op recovery.

A. A middle adult male who is diaphoretic and reports epigastric pain B. An adolescent female client who is belligerent and has slurred speech C. A young adult with a painful sunburn of his face and arms D. A toddler who has a laceration on his forehead and is screaming

Correct Answer is A

Explanation

A. Middle adult male who is diaphoretic and reports epigastric pain
Diaphoresis and epigastric pain can be atypical signs of an MI and require immediate evaluation.

B. Adolescent female who is belligerent and has slurred speech
Could be intoxicated, but not the most urgent.

C. Young adult with painful sunburn
Discomforting but not life-threatening.

D. Toddler with a forehead laceration screaming
Needs attention but is likely stable; crying indicates airway and consciousness are intact.

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A nurse on a mental health unit is caring for a newly admitted client. Exhibits The nurse is continuing to care for the client. Which of the following actions should the nurse take?(Select All that Apply.)

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A nurse on a mental health unit is caring for a newly admitted client.

Exhibits

The nurse is continuing to care for the client. Which of the following actions should the nurse take?(Select All that Apply.)