a male client with schizophrenia is socially reclusive and pacing in the hallway what is the most important intervention for the nurse to implement
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Nursing Elites

HESI RN

HESI 799 RN Exit Exam Capstone

1. A male client with schizophrenia is socially reclusive and pacing in the hallway. What is the most important intervention for the nurse to implement?

Correct answer: D

Rationale: The correct answer is to carefully observe the client throughout the shift. In this situation, the client's behavior suggests agitation and restlessness, which could potentially escalate. Observation is crucial to monitor any changes in behavior, assess for signs of distress, and ensure the client's safety. Taking the client's temperature and blood pressure (Choice A) may not address the immediate need for managing the client's behavior. Encouraging the client to rest (Choice B) might not be effective if the client is highly agitated. Planning an activity that includes physical exercise (Choice C) could exacerbate the situation rather than address the current behavior. Therefore, the priority is to observe the client closely to provide appropriate support and intervention as needed.

2. A client with a urinary tract infection (UTI) is prescribed antibiotics. What is the most important instruction for the nurse to give the client?

Correct answer: B

Rationale: The most crucial instruction for the nurse to give a client with a UTI who is prescribed antibiotics is to complete the full course of antibiotics. Completing the full course of antibiotics is essential to ensure that the infection is fully treated and to prevent the development of antibiotic resistance. While taking antibiotics with food, increasing fluid intake, and managing discomfort with pain relievers are important aspects of UTI management, completing the prescribed course of antibiotics is the top priority to achieve the best treatment outcomes and prevent recurrence of the infection.

3. The nurse observes that a client’s wrist restraint is secured to the side rail of the bed. What action should the nurse take?

Correct answer: B

Rationale: The correct action for the nurse to take is to reposition the restraint tie onto the bedframe. Restraints should always be secured to the bedframe, not the side rails, to prevent injury to the client in case the bed is adjusted. Choice A is incorrect because the issue is with the attachment point, not the snugness of the restraint. Choice C is incorrect as double knotting the restraint does not address the incorrect attachment point. Choice D is incorrect as the nurse should not leave the restraint in the wrong position; instead, it should be moved to the correct location on the bedframe.

4. A client reports unilateral leg swelling after a long flight. What complication is the nurse most concerned about?

Correct answer: A

Rationale: The correct answer is A. Unilateral leg swelling following a long flight may indicate a pulmonary embolism, which is a life-threatening complication requiring immediate attention. Pulmonary embolism occurs when a blood clot travels to the lungs, potentially blocking blood flow and leading to serious complications. Choices B, C, and D are incorrect because dehydration, compartment syndrome, and oxygen saturation levels are not typically associated with unilateral leg swelling after a long flight. While dehydration can cause leg cramps, compartment syndrome is more commonly associated with trauma or injury, and oxygen saturation levels are not the primary concern in this scenario.

5. A client presses the call bell and requests pain medication for a severe headache. To assess the quality of the client's pain, which approach should the nurse use?

Correct answer: C

Rationale: Asking the client to describe the pain is the most appropriate approach to assess the quality of pain. It provides valuable qualitative information that aids in understanding the nature, cause, and potential management strategies for the headache. While pain rating scales like the Wong-Baker Faces scale and using vital signs can help quantify pain severity, they do not offer specific descriptive details that can give insights into the type and characteristics of the pain experienced by the client.

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