An adult patient assaulted another patient and was subsequently restrained. One hour later, which statement by the restrained patient requires the nurse’s immediate attention?
“The other patient started the fight.”.
“I hate all of you.”.
“My fingers are tingling.”.
“You wait until I tell my lawyer.”.
The Correct Answer is C
Choice A rationale
While it’s important to understand the circumstances leading to the assault, this statement does not require immediate attention from the nurse. It’s more related to the incident itself rather than the patient’s current condition.
Choice B rationale
Expressing hatred towards others can be a sign of emotional distress, but it does not require immediate medical attention.
Choice C rationale
Tingling in the fingers can be a sign of reduced blood circulation, which could be a result of the restraints. This requires immediate attention to prevent further complications.
Choice D rationale
While it’s important to address legal threats, this statement does not require immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Step 1 is to determine the amount of medication to administer. The order is for Haldol 2mg IM stat. The available medication is Haldol 5mg/ml. To find out how many ml’s to administer, you would divide the ordered dose by the available dose. So, 2mg ÷ 5mg/ml = 0.4 ml.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A rationale
The absence of suicidal ideation is a positive outcome for a client diagnosed with a depressive disorder. This indicates that the client is not experiencing thoughts of self-harm or death, which is a common symptom of severe depression.
Choice B rationale
Returning to work or school signifies that the client is able to resume normal activities and responsibilities, indicating an improvement in their mental health.
Choice C rationale
While it’s important for the client to report no side effects from medication, it’s not necessarily an expected outcome for a client diagnosed with a depressive disorder. Antidepressant medications can often have side effects, and managing these is part of the treatment process.
Choice D rationale
Expressing hopefulness for the future is a positive sign as it indicates that the client is not experiencing feelings of hopelessness, a common symptom of depression.
Choice E rationale
Regular sleep patterns, such as sleeping for 8 hours each night, are beneficial for mental health and can help in the management of depressive symptoms.
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