A patient is admitted to the mental health unit due to feelings of depression following a positive HIV diagnosis.
Which action should the nurse take to ensure a safe environment for this patient?
Replace paper trash bags with plastic biohazard bags.
Remove soft drink cans from the nurse’s desk and patient lounge.
Confiscate the patient’s cellular phone and provide a room telephone.
Ensure that prescribed medications are securely stored in the room.
The Correct Answer is D
Choice A rationale
Replacing paper trash bags with plastic biohazard bags is not typically necessary in a mental health unit unless there is a risk of exposure to blood or other potentially infectious materials. This action would not specifically address the safety needs of a patient with depression following a positive HIV diagnosis16.
Choice B rationale
Removing soft drink cans from the nurse’s desk and patient lounge is not typically necessary for ensuring a safe environment for a patient with depression following a positive HIV diagnosis. This action does not directly address the patient’s mental health needs16.
Choice C rationale
Confiscating the patient’s cellular phone and providing a room telephone is not typically necessary for ensuring a safe environment for a patient with depression following a positive HIV diagnosis. While some facilities may have policies regarding the use of personal electronic devices, this action does not directly address the patient’s mental health needs16.
Choice D rationale
Ensuring that prescribed medications are securely stored in the room is the correct action. This is a standard safety measure in healthcare settings to prevent medication errors and misuse. It is particularly important for patients with depression who may be at risk for self-harm16.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While auscultating breath sounds is an important part of assessing a client’s respiratory status, it is not the first action the nurse should take when a client with ascites is dyspneic. The nurse should first address the client’s positioning to help alleviate the dyspnea.
Choice B rationale
While measuring vital signs is an important part of assessing a client’s overall status, it is not the first action the nurse should take when a client with ascites is dyspneic. The nurse should first address the client’s positioning to help alleviate the dyspnea.
Choice C rationale
Assisting the client to a high Fowler’s position can help alleviate dyspnea by allowing for greater lung expansion. This should be the nurse’s first action when a client with ascites is dyspneic.
Choice D rationale
While deep breathing exercises can help improve lung function and may be beneficial for a client with ascites, they are not the first action the nurse should take when the client is dyspneic. The nurse should first address the client’s positioning to help alleviate the dyspnea.
Correct Answer is D
Explanation
Choice A rationale
Diaphragmatic respirations are normal in infants and do not necessarily indicate acute respiratory distress.
Choice B rationale
A resting respiratory rate of 35 breaths/min is within the normal range for a 4-month-old infant and does not necessarily indicate acute respiratory distress.
Choice C rationale
Bilateral bronchial breath sounds are normal findings and do not necessarily indicate acute respiratory distress.
Choice D rationale
Flaring of the nares, or nostrils, is a sign of respiratory distress in children. It indicates that the child is having to work harder to breathe.
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