The nurse is sitting with a client diagnosed with schizophrenia, who starts to laugh uncontrollably, although the nurse has not said anything funny. The nurse should say:

"Please share the joke with me."

"You're laughing. Tell me what's happening."

"Why are you laughing?"

"I don't think I said anything funny."

Answer and Explanation

The Correct Answer is B

Choice A Reason:
Asking the client to share the joke may imply that the nurse believes the client is laughing at a joke, which may not be the case. It's important to recognize that uncontrollable laughter can be a symptom of schizophrenia and not necessarily a response to humor.

Choice B Reason:
This response is open-ended and nonjudgmental, inviting the client to explain their behavior without making assumptions. It allows the client to share their experience, which could be related to an internal stimulus such as a hallucination or simply a response they cannot control.

Choice C Reason:
Asking "Why are you laughing?" could be perceived as confrontational or accusatory. It might make the client feel defensive or misunderstood, especially if the laughter is a symptom of their condition and not something they are doing voluntarily.

Choice D Reason:
Saying "I don't think I said anything funny" focuses on the nurse's perspective rather than the client's experience. It could inadvertently dismiss the client's behavior as inappropriate or unjustified, which is not supportive in a therapeutic relationship.

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Correct Answer is A

Explanation

Choice A reason:

Post-operative pain management is a critical aspect of care for a client recovering from a below-the-knee amputation. Administering pain medication as needed helps to manage pain effectively, which is essential for the client's comfort and recovery. Pain control is also important to facilitate participation in rehabilitation activities.

Choice B reason:

It is not advisable to encourage the client to bear weight on the affected limb immediately after surgery. The residual limb needs time to heal, and premature weight-bearing can lead to complications such as delayed healing or wound dehiscence.

Choice C reason:

While it is important to prevent complications such as deep vein thrombosis, complete restriction of mobility and keeping the client on bed rest is not recommended. Early mobilization, as part of a rehabilitation program, is essential for improving circulation, preventing muscle atrophy, and promoting overall recovery.

Choice D reason:

Applying a tight compression bandage on the residual limb is a common practice in the post-operative care of clients with amputations. The compression bandage helps to control swelling, shape the limb for a prosthesis, and prevent fluid accumulation. However, the bandage must be applied correctly to avoid impairing circulation.

A. displays hypervigilance and refuses to attend unit activities. B. is flirtatious toward staff members of the opposite sex. C. urges a suspicious client to hit anyone who stares at him. D. clings to the nurse and asks for advice about inconsequential matters.

Correct Answer is C

Explanation

Choice A Reason
Limit setting may be helpful for a client who displays hypervigilance and refuses to attend unit activities, as it can provide clear expectations and help reduce anxiety. However, this behavior does not pose an immediate risk to the safety of others, making limit setting less essential compared to behaviors that could lead to harm.

Choice B Reason
While being flirtatious toward staff members may be inappropriate and require intervention, it is typically addressed through professional boundaries rather than limit setting. Limit setting in this context would involve clarifying acceptable behaviors within the therapeutic relationship.

Choice C Reason
Urging another client to commit violence is a behavior that necessitates immediate limit setting. This behavior poses a direct threat to the safety of others and disrupts the therapeutic environment. Limit setting here would involve immediate intervention to prevent harm and to maintain a safe environment for all clients.

Choice D Reason
A client who clings to the nurse and seeks advice on inconsequential matters may benefit from limit setting to encourage independence and appropriate use of staff time. However, this behavior is not as disruptive or dangerous as inciting violence, making it a lower priority for limit setting.

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The nurse is sitting with a client diagnosed with schizophrenia, who starts to laugh uncontrollably, although the nurse has not said anything funny. The nurse should say:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing action(s) should the nurse include in the post-op plan of care for a client recovering from a below-the-knee amputation?

Correct Answer is A

Explanation

For which of the following behaviors would limit setting be most essential? The client:

Correct Answer is C

Explanation

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Which intervention by a psychiatric nurse implements the ethical principle of autonomy?

The edited text with the question and the choices labeled from a to d is as follows: The nurse who assesses a client as having paranoid personality disorder is most likely to describe the client as:

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Eight hours postoperative following a total knee replacement, which intervention should the nurse implement for the client?

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