A nurse is speaking with the sibling of a client who refuses to see visitors.
Which of the following actions should the nurse take?.
Encourage the client to visit with the sibling.
Tell the sibling the client does not want visitors.
Arrange for the sibling to visit the client in the dayroom.
Refer the sibling to the client's provider.
The Correct Answer is B
Choice A rationale:
It’s not appropriate to pressure the client into seeing visitors.
Choice B rationale:
It’s important to respect the client’s wishes and communicate them to the sibling.
Choice C rationale:
This could potentially cause distress for the client.
Choice D rationale:
While it might be helpful to involve the provider, the immediate issue can be addressed by the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Restricting interactions with other clients may be necessary in some cases, but it’s not the first precaution to take. The nurse must first ensure the client’s safety.
Choice B rationale:
Documenting the client’s behavior every 2 hr is important, but it’s not the first precaution. The nurse must first ensure the client’s safety.
Choice C rationale:
Implementing 24-hr one-to-one nursing observation is the first precaution the nurse should take. This ensures the client’s safety following an overdose.
Choice D rationale:
Administering prescribed medication via the IM route is not a precaution. It’s a method of medication administration.
Correct Answer is C
Explanation
Choice A rationale:
While liver enzymes are important to monitor for many medications, they are not typically affected by lithium.
Choice B rationale:
Uric acid levels are not typically affected by lithium.
Choice C rationale:
Lithium can affect the sodium levels in the body, making it important to monitor these levels while taking this medication.
Choice D rationale:
Erythrocyte sedimentation rate is not typically affected by lithium.
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