You find a patient on the ﬂoor at shift change. She is awake and alert. She is confused now and was not controlled before being found on the ﬂoor.

What is your first step in the nursing process in this situation?

Leave the patient to get help.

Call the patient’s health-care provider from your cell phone.

Help the patient get up and then document your findings in the chart.

Gather more information by making observations about the patient.

Answer and Explanation

The Correct Answer is D

The first step in the nursing process is assessment, which involves gathering information about the patient’s condition. In this situation, the nurse should make observations about the patient’s physical and mental status, including any signs of injury or distress. This information can then be used to determine the appropriate course of action and provide appropriate care. The other

The other options do not represent the first step in the nursing process and may not be appropriate in this situation.

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Correct Answer is C

Explanation

When faced with an unfamiliar treatment instruction, it is important for the nurse to consult the facility’s policies and procedures to determine the appropriate course of action. These policies and procedures provide guidance on how to carry out treatments safely and eﬀectively and can help ensure that the patient receives the best possible care.

While it may also be appropriate for the nurse to call the physician for clarification (a), check the state’s nurse practice act (b), or contact the nursing supervisor for approval (d), consulting the facility’s policies and procedures should be the first step in determining the appropriate course of action.

A. The nurse practice act. B. The development of psychotropic medications. C. The Community mental health centers act. D. Electroshock therapy.

Correct Answer is B

Explanation

The development of psychotropic medications in the 1950s was a major breakthrough that helped to facilitate the deinstitutionalization movement. These medications helped to manage the symptoms of mental illness and allowed many patients to be treated in community-based settings rather than being confined to institutions. This shift towards community-based care was further supported by the Community Mental Health Centers Act and other initiatives.

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You find a patient on the ﬂoor at shift change. She is awake and alert. She is confused now and was not controlled before being found on the ﬂoor. What is your first step in the nursing process in this situation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An order written by the physician is reviewed by the nursing staﬀ, and no one is familiar with the treatment instructions. A nurse who is recently hired knows that this treatment is covered by the states nurse practice act. What is the nurses’ best course of action?

Correct Answer is C

Explanation

A breakthrough of the 1950s that assisted in the deinstitutionalization movement was:

Correct Answer is B

Explanation

The following types of patients require adaptive communication techniques: (Select all that apply)

While dining in a restaurant the nurse overhears two co-workers in the next booth discussing a client who is being cared for on the mental health unit which they work. What action have the nurse’s co-workers committed for which they could be held liable for?

A nurse just realized that a medication error just occurred. What should the nurse do first?

During a client nurse interaction, which nursing statement may give the client false reassurance?

The nurse in the Emergency Department finds a woman collapsed on the ﬂoor and crying loudly. The woman’s husband was in a car accident and is being attended by the medical staﬀ. Which statement by the medical nurse best demonstrates acting in a culturally competent manner?

A nurse is caring for a client on an acute care mental health unit who was involuntarily admitted for 72 hr. after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?

A nurse tells a client that she will be back in 10 minutes to re-assess the client’s pain. When the nurse returns in 10 minutes, which aspect of the therapeutic relationship is the nurse developing?

While the nurse is talking with a female client, the client becomes quiet for several hours. Which is the nurse’s best response?

You find a patient on the ﬂoor at shift change. She is awake and alert. She is confused now and was not controlled before being found on the ﬂoor.

What is your first step in the nursing process in this situation?