The nurse is assisting in the care of the client who is on the behavioral health unit.
Select words from the choices below to fill in each blank in the following sentence (Separate using commas).
The nurse should plan to
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
The correct answer is choice A and E.
Choice A rationale:
The nurse should plan to ask the client what they are hearing. This is a therapeutic communication technique known as seeking clarification. It allows the nurse to gain more information and understand the client’s perspective. It can also help the client feel heard and validated, which can build trust and rapport.
Choice B rationale:
Telling the client their hallucinations are not real is not recommended. While it’s true that the hallucinations are not real, from the client’s perspective, they are very real and can be very frightening. Telling them otherwise can come across as dismissive and invalidating, which can damage the therapeutic relationship.
Choice C rationale:
Escorting the client to a group meeting may not be appropriate at this time. Given the client’s current state of agitation and confusion, they may not be able to participate effectively in a group setting. It could also potentially disrupt the group dynamic.
Choice D rationale:
Restraining the client should be a last resort and only used when the client is a danger to themselves or others. In this case, while the client is agitated and confused, they do not appear to be an immediate danger.
Choice E rationale:
Reducing excess stimulation around the client can be beneficial in this situation. Excess stimulation can exacerbate symptoms of psychosis such as hallucinations and agitation. By creating a calm and quiet environment, it can help reduce these symptoms and help the client feel more at ease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Hypercalcemia. Hypercalcemia refers to an elevated level of calcium in the blood. It is not typically a concern in a newborn, and monitoring for hypercalcemia is not necessary in this context. The infant's weight and maternal diabetes are more relevant factors to consider.
Choice B rationale:
Hypobilirubinemia. Hypobilirubinemia implies a low level of bilirubin in the blood, which is not a common concern in newborns, especially in the context of a newborn's weight and maternal diabetes. Monitoring for hyperbilirubinemia, which can lead to jaundice, would be more appropriate.
Choice C rationale:
Hypoglycemia. Hypoglycemia, or low blood sugar, is a significant concern in newborns of diabetic mothers. Newborns born to diabetic mothers are at increased risk of hypoglycemia due to the abrupt cessation of the continuous glucose supply from the mother's bloodstream after birth. Monitoring the newborn's blood glucose levels is crucial in this case.
Choice D rationale:
Decreased RBC. Monitoring for decreased red blood cell (RBC) counts is not typically a primary concern in a newborn, especially one born to a diabetic mother. Hypoglycemia, which can be a result of maternal diabetes, poses a more immediate and significant threat to the newborn's well-being.
Correct Answer is B
Explanation
The correct answer is choice b. Charge nurse.
Choice b rationale: The charge nurse is the appropriate personnel to report the incorrect blood glucose monitoring by the assistive personnel. As the nurse in charge of the unit, the charge nurse has the authority and responsibility to address issues related to patient care and ensure that nursing staff, including assistive personnel, are providing care according to facility policies and procedures
Choice a rationale: While the nurse manager is responsible for overseeing the nursing staff and ensuring quality patient care, it is more appropriate to report the incident to the charge nurse first, as they are directly responsible for the unit and can immediately address the issue
Choice c rationale: The risk manager is responsible for identifying, assessing, and mitigating risks within the healthcare facility. While the incorrect blood glucose monitoring could be considered a risk, it is not the primary role of the risk manager to address issues related to patient care. The charge nurse is better positioned to address the immediate concern and ensure proper training or corrective action for the assistive personnel.
Choice d rationale: The nurse supervisor is responsible for overseeing and managing nursing staff, similar to the nurse manager. However, the charge nurse is the more appropriate personnel to report the incident to, as they are directly responsible for the unit and can immediately address the issue
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.