Answer to Question 1
B
Feedback:
The nurse making home visits, particularly to mentally disordered clients, should carry a cell phone and travel with another nurse. The nurse working in home care must be alert to his or her own personal safety. Use of leather restraints and locking clients in their rooms is done as a last resort after all measures have been attempted. Clients who are brought to the hospital from a jail or prison are kept behind locked doors.
Answer to Question 2
A
Feedback:
Whenever a client is admitted to a mental healthcare unit, the nurse should consider the possibility of withdrawal from alcohol or drugs. The use of these substances is very common in this population, and withdrawal can be life threatening. People with no previous psychosis may experience psychiatric symptoms during withdrawal from alcohol or drugs. Documenting any unusual occurrences, such as injuries or altercations, checking for overuse of defense mechanisms in the client, and observing if the person has unprovoked bursts of temper are not the first thing to consider when the client is admitted to a mental healthcare unit.
To check pupillary reflexes the nurse first holds the penlight
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Testing patellar reflex, client in a sitting position
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