The nurse notices a client wandering in the hospital hall giggling, with bizarre behavior that is annoying and frightening other clients. A priority in caring for her is to:
Encourage social interaction.
Discuss the bizarre behavior.
Give the client information about her illness.
Provide a safe environment.
The Correct Answer is D
Choice A Reason:
Encouraging social interaction might not be appropriate in this situation. The client’s bizarre behavior is already causing distress to others, and encouraging more interaction could exacerbate the problem. The priority should be to address the immediate safety and well-being of both the client and others. Once the client is in a safe environment, social interaction can be encouraged in a controlled and therapeutic manner.
Choice B Reason:
Discussing the bizarre behavior with the client might not be effective in the moment, especially if the client is not in a state to understand or engage in such a discussion. The primary focus should be on ensuring safety and stability before addressing specific behaviors. Once the client is calm and in a safe environment, discussions about behavior can be more productive.
Choice C Reason:
Providing information about the client’s illness is important for long-term management and understanding, but it is not the immediate priority in this situation. The client’s current state requires immediate intervention to ensure safety. Education about the illness can be provided once the client is stabilized and in a better position to comprehend the information.
Choice D Reason:
Providing a safe environment is the most immediate and crucial priority. The client’s behavior is not only distressing to others but could also pose a risk to herself and others. Ensuring the client is in a safe, controlled environment helps to prevent harm and allows for further assessment and appropriate interventions. Safety is always the first priority in managing acute behavioral disturbances.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
This will help with medication compliance.
This is the correct response. Long-acting injectable (LAI) antipsychotics like risperidone IM are often used to improve medication compliance in patients who have difficulty remembering to take their oral medications regularly. By administering the medication every two weeks, the treatment team can ensure that the client receives a consistent dose, reducing the risk of relapse due to missed doses. This approach is particularly beneficial for clients with schizophrenia, as consistent medication adherence is crucial for managing symptoms and preventing hospitalizations.
Choice B Reason:
It will help him remember to take his medication.
While this statement is related to medication compliance, it is not entirely accurate. The purpose of switching to an injectable form is to eliminate the need for the client to remember to take daily doses. Instead, the healthcare provider administers the medication at regular intervals, ensuring adherence without relying on the client’s memory.
Choice C Reason:
This has a faster onset of action.
This statement is incorrect. The onset of action for long-acting injectable risperidone is not necessarily faster than the oral form. In fact, LAIs are designed to release the medication slowly over time to maintain stable blood levels. The primary advantage of LAIs is improved adherence, not a faster onset of action.
Choice D Reason:
This new medication is stronger and will clear his symptoms faster.
This statement is also incorrect. The strength of the medication and the speed at which it clears symptoms are not the primary reasons for switching to an injectable form. The goal is to ensure consistent medication levels and improve adherence, not to increase the potency or speed of symptom relief.
Correct Answer is ["B","D","E"]
Explanation
Choice A Reason:
The statement “They do not need to report the use of herbal therapies to the provider” is incorrect. It is crucial for clients to inform their healthcare providers about any herbal therapies they are using. This is because herbal therapies can interact with prescription medications, potentially causing adverse effects or reducing the efficacy of the medications. Healthcare providers need to be aware of all substances a patient is taking to provide safe and effective care.
Choice B Reason:
The statement “Herbal therapies also have side effects and may interact with other medications being taken” is correct. Herbal therapies, despite being natural, can have potent effects on the body and may cause side effects. Additionally, they can interact with other medications, leading to potentially harmful interactions. For example, St. John’s wort can interact with antidepressants, and ginkgo biloba can affect blood clotting. Therefore, it is essential to consider these interactions when using herbal therapies.
Choice C Reason:
The statement “They need to stay away from all herbal therapies” is incorrect. While it is important to be cautious, it is not necessary to avoid all herbal therapies. Many herbal therapies can be beneficial when used appropriately and under the guidance of a healthcare provider. The key is to ensure that the herbal products are safe, effective, and do not interact negatively with other medications the client may be taking.
Choice D Reason:
The statement “Herbal therapies should be purchased from reliable manufacturers with a history of quality control of their product” is correct. The quality of herbal products can vary significantly between manufacturers. Choosing products from reputable manufacturers ensures that the products have been tested for purity, potency, and safety. Reliable manufacturers follow good manufacturing practices and have stringent quality control measures in place, reducing the risk of contamination and ensuring the product’s efficacy.
Choice E Reason:
The statement “They should always inform healthcare providers of the use of herbs” is correct. It is essential for clients to inform their healthcare providers about any herbal therapies they are using. This information helps healthcare providers to monitor for potential interactions and side effects, adjust medication dosages if necessary, and provide comprehensive care. Open communication between clients and healthcare providers is crucial for ensuring safe and effective treatment plans.
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