A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively.
Which action is the priority?

Maintain trust and avoid behaviors that may increase agitation.

Order the client to go to their room & alert security.

Tell the client to sit down or risk isolation and loss of privileges.

Sedate the client after collecting a lithium level.

Answer and Explanation

The Correct Answer is A

Maintain trust and avoid behaviors that may increase agitation. This is because the client is likely experiencing a manic episode, which is characterized by increased activity, rapid speech, and decreased need for sleep. The nurse should use a calm and supportive approach, provide a safe and structured environment, and avoid confrontation or criticism.

Choice B is wrong because ordering the client to go to their room and alerting security would escalate the situation and violate the client’s rights.

Choice C is wrong because telling the client to sit down or risk isolation and loss of privileges would be threatening and punitive, which could increase the client’s agitation and anger.

Choice D is wrong because sedating the client after collecting a lithium level would be premature and inappropriate without a physician’s order and without assessing the client’s vital signs, mental status, and medication history. Lithium is a mood stabilizer that can cause toxicity if the level is too high.

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Correct Answer is ["A","C"]

Explanation

These interventions help the client to cope with stress by enhancing their social support and teaching them skills to manage stressors.

Choice B is wrong because sedative hypnotics may cause dependence and do not address the underlying causes of stress.

Choice D is wrong because discussing factors that contribute to stress may increase the client’s anxiety and does not provide any solutions.

The normal range for coping is to use adaptive strategies that reduce stress and promote well-being.

A. Increased heart rate. B. Decreased blood pressure. C. Increased temperature. D. Hypoactive muscle responses. E. Alert and oriented.

Correct Answer is ["A","B"]

Explanation

A client with dehydration will have increased heart rate and decreased blood pressure due to the loss of fluid volume and the compensatory mechanisms to maintain cardiac output.

Choice C is wrong because dehydration does not cause increased temperature, but rather decreased temperature due to reduced blood flow to the skin.

Choice D is wrong because dehydration causes hyperactive muscle responses, such as muscle cramps, twitching, and tetany.

Choice E is wrong because dehydration can cause altered mental status, such as confusion, lethargy, or coma. Normal ranges for heart rate are 60-100 beats per minute, blood pressure is 120/80 mm Hg, and temperature is 36.5-37.5°C (97.7-99.5°F).

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A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively. Which action is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When a client has a nursing diagnosis of Ineffective Coping, which nursing interventions would best meet the desired outcome of demonstrating appropriate coping strategies? (Select all that apply).

Correct Answer is ["A","C"]

Explanation

A middle-aged adult client with nausea and vomiting for three days presents to the emergency room. Which findings should the nurse expect to assess in a client diagnosed with dehydration? Select all that apply.

Correct Answer is ["A","B"]

Explanation

Which assessment finding would be considered normal in an elderly client?

A nurse is admitting a client with an exacerbation of chronic obstructive pulmonary disease. What signs would the nurse expect to observe with this client? Select all that apply.

Which action should a nurse plan for a client who has episodes of acute anxiety?

A 75-year-old client has a baseline oral temperature of 96.8° F (36° C). Two hours later the client’s oral temperature is 100.8° F (38.2° C). Which action should a nurse take next?

A health care provider prescribes guaifenesin with dextromethorphan 1 tablespoon every 6 hours for a client who has a nonproductive cough. How many milliliters should a nurse administer for each dose?

When evaluating a client for a tendency toward addictive behaviors, the nurse would expect which findings?

Which is the most appropriate action when obtaining a sterile urine specimen from an indwelling urinary catheter?

The nurse is assessing a client presenting with diazepam intoxication. What signs and symptoms are consistent with benzodiazepine intoxication? Select all that apply.

A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively.
Which action is the priority?