A nurse working in a mental health facility is caring for a client who is pacing back and forth in the day room while wringing their hands. Which of the following actions should the nurse take?

Ask the client if they would like to watch television.

Use short, simple sentences when speaking with the client.

Allow the client to have 1 hr of time alone in their room.

Move the client to a table where other clients are playing cards.

Answer and Explanation

The Correct Answer is B

By using short, simple sentences, the nurse can effectively communicate with the client who is exhibiting signs of agitation and anxiety. This communication style can help reduce stress and confusion for the client and promote understanding.

Asking the client if they would like to watch television: While providing options for activities can be beneficial, it is important to address the client's current state of agitation and anxiety before suggesting any specific activities.

Allowing the client to have 1 hour of time alone in their room: While some clients may prefer solitude, in this case, the client's pacing and hand-wringing indicate signs of distress and may require therapeutic interventions rather than isolation.

Moving the client to a table where other clients are playing cards: This option may not address the client's current state of anxiety and pacing. Placing the client in a social setting with other clients might increase their distress and agitation.

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Correct Answer is A

Explanation

Explanation

A. Placement of a central venous catheter

Informed consent is a legal and ethical requirement that ensures clients have the necessary information to make autonomous decisions about their healthcare. The healthcare provider must obtain informed consent before performing any procedure that carries potential risks or benefits. Here's why the other options do not typically require informed consent:

Administration of an iron injection using Z-track technique in (option B) is not correct because, while informed consent may be required for administering certain medications or injections, the specific technique used, such as the Z-track technique, typically does not require separate informed consent. The Z-track technique is a method used to prevent leakage of the medication into subcutaneous tissues during injection.

Insertion of a nasogastric tube in (option C) is not correct because Insertion of a nasogastric tube is a common procedure performed to access the stomach or administer medications or nutrients. Informed consent is generally not required for nasogastric tube insertion as it is considered a routine procedure and is often included as part of the overall plan of care.

Irrigation of a wound with antibiotic solution in (option D) is not correct because wound irrigation is a standard procedure in wound care, and the use of an antibiotic solution may be part of the healthcare provider's prescribed treatment plan. Informed consent is typically not required for wound irrigation unless there are specific circumstances or risks associated with the procedure.

In summary, the nurse should identify that informed consent is required for A: Placement of a central venous catheter. This procedure involves the insertion of a catheter into a major blood vessel and carries potential risks and complications that require informed consent to ensure the client's understanding and agreement before proceeding

A. Dry mucous membranes B. Trousseau's sign C. Hyperactive reflexes D. Irregular heart rate

Correct Answer is D

Explanation

Hyperkalemia refers to an elevated level of potassium in the blood. It can have various manifestations, and one of the critical effects of hyperkalemia is its impact on cardiac function. High levels of potassium can disrupt the normal electrical conduction in the heart, leading to arrhythmias or irregular heart rate. These arrhythmias can range from mild palpitations to more severe and life-threatening conditions like ventricular fibrillation.

Dry mucous membranes are more commonly associated with dehydration or reduced fluid intake. Hyperkalemia does not directly cause dry mucous membranes.

Trousseau's sign is a clinical manifestation of hypocalcemia, not hyperkalemia. It is characterized by carpal spasm induced by inflating a blood pressure cuff above the client's systolic blood pressure for a few minutes.

Hyperactive reflexes are commonly seen in conditions such as hyperthyroidism or certain neurologic disorders. They are not directly related to hyperkalemia.

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A nurse working in a mental health facility is caring for a client who is pacing back and forth in the day room while wringing their hands. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

Correct Answer is A

Explanation

A nurse is collecting data from a client who is in renal failure. The nurse should identify that which of the following findings is a manifestation of hyperkalemia?

Correct Answer is D

Explanation

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