The nurse on the brain injury unit observes a patient who displays inappropriate sexual behavior. What would be the best response by the nurse?
Initiate a 1:1 observation status
Point out the behavior as unacceptable
Ask the patient why they are behaving that way
Have the patient return to his room
The Correct Answer is B
A. 1:1 observation may be excessive unless the behavior is persistent and unmanageable.
B. Pointing out the behavior as unacceptable provides immediate feedback and helps the patient understand social boundaries, which can be challenging post-brain injury. This approach is direct and respectful, focusing on redirection rather than punishment.
C. Asking why may not be effective, as the patient may lack insight into their behavior due to the brain injury.
D. Having the patient return to their room could seem punitive and does not address the need for behavior modification.
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Correct Answer is C
Explanation
A. Antibiotics are not typically used unless there is a specific infection; Meniere's is not caused by an infection.
B. Beta blockers are used for various cardiovascular conditions and may help with some vestibular disorders, but they are not the first-line treatment for Meniere's Disease.
C. Diuretics are commonly prescribed for Meniere's Disease to help reduce fluid retention and decrease endolymphatic pressure in the inner ear, which can help alleviate symptoms such as vertigo and hearing loss.
D. Antidepressants are not a primary treatment for Meniere's Disease, although they might be prescribed for anxiety or depression that may accompany the chronic nature of the disease.
Correct Answer is D
Explanation
A. While using a cane or walker may be necessary for some patients experiencing balance issues, it is not a specific instruction related to phenytoin.
B. Phenytoin dosages should not be adjusted solely based on observed seizure activity; the dose must be managed carefully based on serum drug levels and the clinician's guidance.
C. Patients on phenytoin typically require more frequent monitoring of blood levels (every 2-3 months initially) rather than annually, as maintaining therapeutic levels is essential to avoid toxicity or ineffective seizure control.
D. Regular dental visits are crucial for patients taking phenytoin because the medication can cause gingival hyperplasia (overgrowth of gum tissue), which necessitates careful dental hygiene and regular monitoring by a dentist to prevent complications.