The nurse is assigned to care for a client diagnosed with psoriasis. Which behavior by the nurse addresses this client's psychosocial need for acceptance?

Wearing gloves when interviewing the client.

Allowing the client to ventilate feelings.

Encouraging the client to join a support group.

Shaking the client's hand during an introduction.

Answer and Explanation

The Correct Answer is D

A.   Wearing gloves when interviewing the client. This behavior may make the client feel stigmatized or rejected, as it could imply that the nurse perceives them as contagious or untouchable.
B.   Allowing the client to ventilate feelings. While this is important for emotional support, it does not directly address the psychosocial need for acceptance.
C.   Encouraging the client to join a support group. This can help the client feel less isolated and gain support from others with similar experiences, but it is not as immediate or direct as personal interaction.
D.   Shaking the client's hand during an introduction. This gesture of physical contact can significantly convey acceptance and normalcy, helping the client feel respected and accepted despite their condition.

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Correct Answer is C

Explanation

A. While repeated requests for attention from the nurse might indicate distress, they are not necessarily indicative of potential aggression or disruptive behavior.
B. Periodic sighing and shaking the head could suggest the client's emotional state, but they are not as indicative of potential aggression or disruptive behavior as argumentativeness and profanity.
C. Monitoring for argumentativeness and the use of profanity is crucial as they can escalate into disruptive or potentially aggressive behavior. It's important to assess the client's agitation level and ensure the safety of both the client and others on the mental health unit.

D. Decreased activity level and a change in affect may suggest a worsening of the client's mental state but are not immediate concerns in terms of safety on the unit.

A. Compare muscle strength bilaterally. B. Determine apical pulse rate and rhythm. C. Assess strength of deep tendon reflexes. D. Observe color and amount of urine.

Correct Answer is B

Explanation

A. Compare muscle strength bilaterally. While hyperkalemia can lead to muscle weakness, assessing muscle strength bilaterally is not the most critical intervention in this scenario. The priority is to assess for cardiac manifestations of hyperkalemia.
B. Determine apical pulse rate and rhythm. Hyperkalemia can cause life-threatening cardiac dysrhythmias, including bradycardia, heart block, and ventricular tachycardia. Assessing the apical pulse rate and rhythm can provide essential information about cardiac function and help identify potential dysrhythmias.
C. Assess strength of deep tendon reflexes. Hyperkalemia can affect neuromuscular function, leading to hyperreflexia or diminished reflexes. While assessing deep tendon reflexes is
important, it is not as critical as assessing cardiac function in a client with known hyperkalemia.
D. Observe color and amount of urine. While changes in urinary output and characteristics may indicate renal impairment associated with hyperkalemia, the priority in this situation is to assess for cardiac manifestations of hyperkalemia.

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The nurse is assigned to care for a client diagnosed with psoriasis. Which behavior by the nurse addresses this client's psychosocial need for acceptance?

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Naxlex Comprehensive Predictor Exams

A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors are most important for the nurse to monitor?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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