A client has been placed in seclusion because the client has been deemed a danger to others. Which is the priority nursing intervention for this client?

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Question 1 of 9

A client has been placed in seclusion because the client has been deemed a danger to others. Which is the priority nursing intervention for this client?

Correct Answer: C

Rationale: The correct answer is C because maintaining contact and assuring the client that seclusion will maintain their safety is the priority nursing intervention for a client deemed a danger to others. This intervention helps build trust, reduce anxiety, and promote a therapeutic relationship. A: Having little contact with the client may increase feelings of isolation and exacerbate the client's distress. B: Providing privacy is important, but in this case, ensuring the client's safety is the priority over maintaining confidentiality. D: Teaching relaxation techniques and coping strategies is beneficial, but it is not the immediate priority when the client is in seclusion due to being a danger to others.

Question 2 of 9

A 3-year-old child has been admitted to the hospital after an automobile accident. Which statement by the nurse would be most appropriate when discussing the type of behavior the parents can expect their child to display while hospitalized?

Correct Answer: B

Rationale: The correct answer is B: Your child may seem unduly anxious in the presence of strangers. This response is most appropriate as it aligns with the typical behavior of young children who have experienced a traumatic event like an automobile accident. Children at this age may exhibit increased anxiety and fear when around unfamiliar individuals due to the stress and uncertainty of their situation. This behavior is a common reaction to trauma. Choice A is incorrect because while changes in appearance may impact the child, it is not the most immediate concern in this scenario. Choice C is incorrect as guilt feelings are less likely to be prominent in a 3-year-old child. Choice D is also incorrect as mood swings are not the primary behavior expected in this situation, and the statement lacks specificity compared to the appropriate response.

Question 3 of 9

A patient with a history of anger and impulsivity was hospitalized after an accident resulting in multiple injuries. The patient loudly scolds nursing staff, 'I'm in pain all the time but you don't give me medicine until YOU think it's time.' Which nursing intervention would best address this problem?

Correct Answer: B

Rationale: The correct answer is B because switching from prn (as-needed) pain medication to patient-controlled analgesia empowers the patient to manage their pain effectively, addressing the issue of feeling powerless and dependent on nursing staff for pain relief. This intervention also aligns with the patient's impulsivity and need for immediate gratification. Choice A is incorrect because teaching coping strategies may not address the immediate pain relief the patient desires. Choice C is incorrect as it focuses on addressing the behavior without addressing the underlying issue of pain management. Choice D is incorrect because it does not provide a solution to the immediate problem of pain control and may not be relevant to the patient's current behavior.

Question 4 of 9

A female client who is receiving counseling at a community health center has complained about being unable to sleep at each of the last three weekly sessions. The nurse interviews the family members to determine the effect of the client's problem on them. Which response would the nurse most likely expect to hear?

Correct Answer: D

Rationale: The correct answer is D because the nurse would expect family members to express the negative impact of the client's sleep problem. Lack of sleep can lead to irritability and mood disturbances, affecting family dynamics. Choice A is incorrect as it dismisses the issue. Choice B is incorrect as it suggests no change, which is unlikely. Choice C is incorrect as lack of sleep typically does not have a positive effect on individuals or their families.

Question 5 of 9

The nurse has explained some of the biologic theories of causation to a client diagnosed with borderline personality disorder and his family. The nurse determines that the client and family have understood the instructions when they state which of the following?

Correct Answer: C

Rationale: Rationale: Choice C is correct because borderline personality disorder is believed to be associated with frontal lobe dysfunction, impacting emotional regulation and impulsivity. The frontal lobe plays a crucial role in personality development. Choices A, B, and D are incorrect because there isn't conclusive evidence linking the disorder to increased serotonin or decreased dopamine activity, or hormonal imbalances.

Question 6 of 9

During the stabilization phase of drug therapy for a patient who is hospitalized with a psychiatric disorder, which action would be most appropriate?

Correct Answer: D

Rationale: The correct answer is D because during the stabilization phase, assessing the patient for target symptoms and side effects is crucial to ensure the medication is working effectively without causing harm. This step allows healthcare providers to monitor the patient's progress, adjust the medication dosage if needed, and address any emerging side effects promptly. A: Discussing the timing of tapering the medication is premature during the stabilization phase as the focus should be on monitoring the patient's response to the current medication regimen. B: Instructing the patient about relapse prevention is important but more relevant during the maintenance phase rather than the stabilization phase. C: Determining if the medication is losing its effect can be part of the assessment but is not the most appropriate action during the stabilization phase where the primary focus is on monitoring symptoms and side effects.

Question 7 of 9

Assessment of an older adult client reveals that the client is receiving psychiatric medications. The client states, 'I get dizzy periodically and have trouble walking.' Which of the following should the nurse do first?

Correct Answer: A

Rationale: The correct answer is A: Compare the client's baseline blood pressure with the client's current blood pressure. This is the first step to assess for orthostatic hypotension which can be a side effect of psychiatric medications. It is important to rule out any potential medication-induced hypotension before making any changes to the client's medication regimen. Choice B is incorrect because abruptly stopping psychiatric medications can lead to withdrawal symptoms and exacerbate the client's condition. Choice C is incorrect because while assessing coping skills and stress levels is important, addressing the client's current symptoms of dizziness and difficulty walking takes precedence. Choice D is incorrect as using an alcohol-based mouthwash is unrelated to the client's symptoms and may not address the underlying cause of the client's issues.

Question 8 of 9

The nurse is working as part of the interdisciplinary staff of a psychiatric inpatient facility who are developing discharge plans for a patient who requires alternative housing arrangements. The patient will be referred to a personal care home. When explaining this housing arrangement to the patient, which of the following would the nurse include?

Correct Answer: D

Rationale: The correct answer is D because personal care homes typically house a small number of residents (6-10 people) and provide 24-hour supervision by health care attendants. This option aligns with the concept of personal care homes offering a more intimate and personalized level of care compared to larger facilities. Choice A is incorrect because personal care homes are not typically run by families, and the level of supervision provided is more formal and professional. Choice B is incorrect as personal care homes do not usually involve residents living in apartments with roommates. Choice C is incorrect because personal care homes typically do not house 50 people together and provide more personalized care in smaller groups.

Question 9 of 9

Which principle has the highest priority when addressing a behavioral crisis in an inpatient setting?

Correct Answer: A

Rationale: Step-by-step rationale for why choice A is correct: 1. Safety of all individuals is paramount in an inpatient setting. 2. Least restrictive intervention aligns with ethical principles and respects individual autonomy. 3. It prioritizes de-escalation techniques over coercive measures. 4. Emphasizes the importance of promoting patient dignity and minimizing harm. 5. Encourages collaborative problem-solving and empowerment of the individual. Summary of why other choices are incorrect: B. Swift intervention may escalate the crisis and disregard patient autonomy. C. Majority rule does not justify violating individual rights in a mental health setting. D. Allowing patients to regain control without intervention can pose risks to themselves and others.

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