The day nurses in a psychiatric unit are receiving report from ...

[laurencescou]

The day nurses in a psychiatric unit are receiving report from the night shift. While this is occurring, a client approaches the nurses' station, becomes very loud and offensive, and demands to be seen by the physician immediately.
 
  The appropriate nursing intervention is which of the following? 1. Inform the client that the behavior is unacceptable.
  2. Tell the client to wait in his or her room until report is over.
  3. Offer to assist the client to an examination room until the physician is notified.
  4. Tell the client that the physician will be called as soon as report is completed.

Question 2

The nurse reviews the plan of care for a child with Reye's syndrome. The nurse prioritizes the nursing interventions included in the plan and prepares to monitor for:
 
  1. Signs of hyperglycemia
  2. Signs of a bacterial infection
  3. The presence of protein in the urine
  4. Signs of increased intracranial pressure

[sierramartinez]

Answer to Question 1

3

Rationale: Safety of the client, other clients, and staff is of prime concern when dealing with a client who may be angry and demanding. Offering to assist the client to an examination room until the physician is notified is in effect an isolation technique that allows for separation from others and provides a less stimulating environment, where the client can maintain dignity. In-form the client that the behavior is unacceptable, tell the client to wait in his or her room until report is over, and tell the client that the physician will be called as soon as report is complet-ed place the client's concern on hold and will only cause the behavior to escalate.

Answer to Question 2

4

Rationale: Intracranial pressure and encephalopathy are major symptoms of Reye's syndrome. Protein is not present in the urine. Reye's syndrome is related to a history of viral infections, and hypoglycemia is a symptom of this disease.

[laurencescou]

Excellent

[scottmt]

TYSM