Nokea
A client is becoming increasingly agitated
- A. anxious
- B. and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?
- C. Verbally de-escalate the client.
- D. Take the client to the seclusion room.
- E. Place the client in restraints.
- F. Obtain a prescription for haloperidol.
Correct Answer: A
Rationale: Verbally de-escalating the client is the first step to reduce agitation and prevent escalation. This non-invasive approach prioritizes safety and communication.
You may also like to solve these questions
A nurse is preparing to administer sertraline 50 mg PO once daily to a client who has depressive disorder. Available is sertraline oral solution 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 2.5
Rationale: Step 1: (50 mg ÷ 20 mg/mL) × 1 mL = 2.5 mL. The nurse should administer 2.5 mL to deliver the prescribed 50 mg dose, calculated based on the concentration of the available solution.
A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states
- A. That looks like a snake
- B. and I won't let it take all of my blood.' Which of the following responses should the nurse make?
- C. I don’t see a snake, but that must be scary for you.
- D. I’m using a syringe to obtain your blood, not a snake.
- E. Your provider requires this blood specimen.
- F. You must be mistaken.
Correct Answer: A
Rationale: Acknowledging the client's fear and providing reassurance without confirming the hallucination helps build trust and reduce anxiety. This empathetic response supports the client’s emotional state.
A nurse is caring for a client who is experiencing a situational crisis. Which of the following actions should the nurse take first?
- A. Assist with a client referral for social services.
- B. Identify if the client has thoughts of self-harm.
- C. Reinforce teaching on the client's use of coping skills.
- D. Encourage the client to use personal support systems.
Correct Answer: B
Rationale: Identifying thoughts of self-harm is crucial for immediate safety and risk management, making it the priority action. This ensures the client’s well-being is secured before addressing other needs.
A nurse is contributing to the plan of care for a client who has acute delirium. Which of the following interventions should the nurse include in the plan of care?
- A. Limit the client's need to make decisions.
- B. Discourage visitation from the client's family.
- C. Keep the client's room dark at night.
- D. Provide a high-stimulation environment for the client.
Correct Answer: A
Rationale: Limiting the client's need to make decisions helps reduce stress and confusion, which can exacerbate symptoms of delirium. Simplifying choices and providing a structured environment can aid in orientation and reduce cognitive overload.
A nurse is caring for a group of clients in a pediatric clinic. Which of the following clients is at highest risk for physical abuse?
- A. An adolescent who is preparing to leave home for college.
- B. A preschooler who is reluctant to share.
- C. A school-age child who wants to go away to summer camp.
- D. A toddler who has cystic fibrosis.
Correct Answer: D
Rationale: Toddlers with chronic illnesses like cystic fibrosis may be at higher risk for physical abuse due to the increased stress and demands on caregivers. This vulnerability elevates their risk compared to typically developing peers.