The nurse reviewed the nurses’ notes, provider’s note, and vital signs at 0415.

Exhibits

Which of the following interventions should the nurse include in the client’s care? Select the three interventions the nurse should implement.

Limit visitation from the client’s family.

Reorient the client to person, place, and time frequently.

Rotate nursing staff daily.

Approach the client slowly.

Maintain a low-stimulation environment.

Answer and Explanation

Correct Answer : B,D,E

Choice A reason: Limiting visitation from the client’s family may not be beneficial as the presence of familiar people can often help reorient and calm the client. Family members can provide comfort and reassurance, which can be particularly helpful for a client experiencing delirium.
Choice B reason: Reorienting the client to person, place, and time frequently is a recommended intervention for patients with delirium. This can help reduce confusion and agitation in clients with delirium.
Choice C reason: Rotating nursing staff daily could potentially increase confusion for the client, as continuity of care and familiar faces can be beneficial in managing delirium. Therefore, this option is not recommended.
Choice D reason: Approaching the client slowly is a recommended intervention for patients with delirium. Given the client’s agitation and confusion, it’s important to approach them in a non-threatening manner to avoid escalating their distress.
Choice E reason: Maintaining a low-stimulation environment is a recommended intervention for patients with delirium. A calm and quiet environment can help reduce agitation and confusion in clients with delirium.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is []

Explanation

Potential Condition The client is most likely experiencing b. Antisocial personality disorder. This is suggested by the client’s lack of remorse, impulsivity, deceitfulness, and aggressive behavior when denied something she wants.

Actions to Take To address this condition, the nurse should:

a. Assess history of criminal behavior: This can provide insight into the severity and pattern of the client’s antisocial behavior.
e. Establish clear and realistic boundaries regarding behavior: This can help manage the client’s impulsivity and aggressive behavior.

Parameters to Monitor To assess the client’s progress, the nurse should monitor:

c. Aggressive and violent behavior: Any reduction in these behaviors can indicate improvement.
e. Deceitfulness: A decrease in deceitful behavior can also signal progress.

A. Identify when the client engages in splitting behaviors. B. Give the client a choice of solitary activities. C. Assist the client in identifying sources of anger. D. Set limits on the client's need for constant social contact with others.

Correct Answer is B

Explanation

Choice A reason:
The statement "Identify when the client engages in splitting behaviors" is not appropriate for schizoid personality disorder. Splitting behaviors are more commonly associated with borderline personality disorder, where individuals may view others as all good or all bad. Schizoid personality disorder is characterized by a preference for solitary activities and emotional detachment.

Choice B reason:
The statement "Give the client a choice of solitary activities" is the correct response. Individuals with schizoid personality disorder often prefer solitary activities and may feel more comfortable engaging in them. Providing options for solitary activities respects their preferences and helps them feel more at ease in the care environment.

Choice C reason:
The statement "Assist the client in identifying sources of anger" is not typically relevant for schizoid personality disorder. These individuals often appear emotionally detached and may not express anger or other strong emotions openly. This intervention is more suited for personality disorders where emotional dysregulation is a primary concern.

Choice D reason:
The statement "Set limits on the client's need for constant social contact with others" is not applicable. Clients with schizoid personality disorder usually do not seek constant social contact; instead, they prefer to be alone and avoid social interactions. Setting limits on social contact is unnecessary and does not address their primary needs.

View Question and Answer

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

The nurse reviewed the nurses’ notes, provider’s note, and vital signs at 0415. Exhibits Which of the following interventions should the nurse include in the client’s care? Select the three interventions the nurse should implement.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client. Exhibits Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Correct Answer is []

Explanation

A nurse is initiating a plan of care for a newly admitted client who has schizoid personality disorder. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take a prescribed oral antianxiety medication. Which of the following actions should the nurse take?

A nurse is providing teaching about relapse prevention to a client who has schizophrenia. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is planning care for a client who has complicated grieving following the death of her child. Which of the following interventions should the nurse identify as the priority?

A nurse is caring for a client who has Alzheimer's disease. Which of the following findings should the nurse expect?

A nurse is caring for a school-age child who has conduct disorder and is in physical restraints after becoming physically aggressive toward other clients on the unit. Which of the following actions should the nurse take?

A nurse is caring for a client who has bipolar disorder and is refusing to take prescribed medications. Which of the following ethical principles is the nurse displaying when he supports the client's refusal of medications?

A nurse in a mental health clinic is assessing a client who has borderline personality disorder. Which of the following findings should the nurse expect?

The nurse reviewed the nurses’ notes, provider’s note, and vital signs at 0415.

Exhibits

Which of the following interventions should the nurse include in the client’s care? Select the three interventions the nurse should implement.