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 A
Explanation
Choice A rationale
Osteoarthritis is a joint disease in which the tissues in the joint, including the cartilage, break down over time. The degradation of joint cartilage is the primary pathological condition that leads to the symptoms of osteoarthritis, such as increased pain and stiffness.
Choice B rationale
A systemic inflammatory response is not the primary cause of osteoarthritis. While inflammation can occur in the affected joint, osteoarthritis is not a systemic inflammatory disease like rheumatoid arthritis.
Choice C rationale
An infectious process in the synovial fluid is not typically associated with osteoarthritis. Infections can lead to a different type of arthritis known as septic arthritis.
Choice D rationale
A decrease in bone mineral density is associated with osteoporosis, not osteoarthritis. In osteoarthritis, the issue is primarily with the degradation of cartilage, not a loss of bone density.
Correct Answer is B
Explanation
Choice A rationale
Noting the presence of an auscultatory gap, which is a period of abnormal silence in Korotkoff sounds during blood pressure measurement, is important. However, in this case, the silence followed by a Korotkoff sound is a normal finding and does not indicate an auscultatory gap.
Choice B rationale
After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. This is a normal finding and indicates that the nurse should continue with the blood pressure assessment.
Choice C rationale
Re-inflating the cuff to a higher number is not necessary in this case as the initial silence followed by a Korotkoff sound is a normal finding.
Choice D rationale
Repositioning the stethoscope over the brachial artery may not resolve the issue of hearing silence followed by a Korotkoff sound. It is important to assess the situation further before making adjustments.
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