A nurse on an acute care mental health unit is caring for a client who has generalized anxiety disorder. The client received an upsetting telephone call and is now rapidly pacing the corridors of the unit. Which of the following actions should the nurse take?

Allow the client to pace alone until physically tired.

Walk with the client at a gradually slowing pace.

Ask a small group of other clients to walk with the client.

Calmly instruct the client to stop pacing and sit in the dayroom.

Answer and Explanation

The Correct Answer is B

The nurse should walk with the client at a gradually slowing pace when caring for a client with a generalized anxiety disorder who is rapidly pacing the corridors of the unit. This intervention provides the client with support and helps to prevent the client from becoming overwhelmed or getting injured. Allowing the client to pace alone until physically tired.

choice A can increase the sense of isolation and anxiety. Asking a small group of other clients to walk with the client.

choice C may be inappropriate or even harmful in some cases. Calmly instructing the client to stop pacing and sit in the dayroom.

choice D can be perceived by the client as dismissive and may escalate the anxiety level. The nurse should work with the client and their family to develop an individualized plan of care that meets the client's needs and goals.

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Correct Answer is A

Explanation

The nurse should determine the patient's triage level and examine and stabilize the patient as needed when caring for a patient without health insurance who is limping and dripping blood from a head wound in the Emergency department. This intervention is the priority because the patient could be at risk of life-threatening complications if their condition is left untreated. Giving the patient information about facilities that specialize in treating people without health insurance, choice B, and asking the patient to sign in and provide method of payment for services, choice C, may be necessary but are not the priority at this time. Transferring the patient to a hospital that specializes in traumatic brain injuries, choice D, may be necessary after stabilizing the patient, but it is not the priority at this time.

A. 3-year-old toddler with scalding burns over the face and chest reportedly sustained when the child pulled on tablecloth, spilling a cup of tea on himself. B. 6-year-old child who has a spiral fracture of the tibia and fibula, which reportedly occurred while riding a bicycle. C. 14-month-old toddler who is reportedly learning to walk and has several bruises on bony prominences of the lower legs and elbows. D. 9-month-old infant who sustained near drowning when he reportedly climbed into the tub and turned on the water.

Correct Answer is B

Explanation

Answer: B. 6-year-old child who has a spiral fracture of the tibia and fibula, which reportedly occurred while riding a bicycle.

Rationale:

A) 3-year-old toddler with scalding burns over the face and chest reportedly sustained when the child pulled on a tablecloth, spilling a cup of tea on himself:

Scalding burns in young children can be accidental, especially if the burns are consistent with typical patterns seen in such accidents. However, burns covering a large area, especially on the face and chest, may warrant further investigation to rule out abuse, particularly if the explanation seems inconsistent with the injury.

B) 6-year-old child who has a spiral fracture of the tibia and fibula, which reportedly occurred while riding a bicycle:

A spiral fracture is often associated with a twisting or rotational force, which is less common in typical bicycle accidents. Spiral fractures in children can be indicative of physical abuse, particularly if the explanation for the injury does not fit the typical mechanisms of injury associated with the reported activity. This type of fracture should prompt a thorough evaluation for possible abuse.

C) 14-month-old toddler who is reportedly learning to walk and has several bruises on bony prominences of the lower legs and elbows:

Bruises on bony prominences are common in toddlers who are learning to walk and are prone to minor falls. This pattern of bruising is usually consistent with typical developmental activities rather than abuse. However, repeated or severe bruising should still be evaluated carefully.

D) 9-month-old infant who sustained near drowning when he reportedly climbed into the tub and turned on the water:

While near drowning in an infant is a serious concern, it is less likely to be related to physical abuse if the explanation involves an accidental event. A thorough assessment is necessary to ensure safety and prevent further incidents, but the described scenario is not as indicative of abuse as a spiral fracture.

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A nurse on an acute care mental health unit is caring for a client who has generalized anxiety disorder. The client received an upsetting telephone call and is now rapidly pacing the corridors of the unit. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient without health insurance comes into the Emergency department limping and dripping blood from a head wound. Which of the following should be done first for this patient?

Correct Answer is A

Explanation

A nurse is caring for four clients at an urgent care center. Which of the following clients should the nurse suspect has been physically abused?

Correct Answer is B

Explanation

A nurse is discussing comorbidities associated with eating disorders with a newly licensed nurse. Which of the following comorbidities should the nurse include in the discussion? (Select all that apply.)

Which statement by the client indicates an understanding of the information provided about sertraline?

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A nurse is collecting data from an adolescent client who has anorexia nervosa. Which of the following findings should the nurse expect?

A nurse is caring for a client following major spinal surgery who is reporting pain. The client's partner tells the nurse, "I wish I could do something to make my wife feel better." Which of the following responses should the nurse make?

The mortality rate for burns is highest in the elderly population. What factors put the very elderly at a high risk? (Select all that apply.)

A nurse is contributing to the plan of care for a child who has autism spectrum disorder. Which of the following interventions should the nurse recommend for the plan of care?

A nurse in a community clinic is caring for a 20-month-old toddler who has spiral fractures of the right ulna and radius. Which of the following findings should the nurse recognize as a potential indication of abuse?