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A client with post-traumatic stress disorder (PTSD) is experiencing a dissociative disorder episode. The situation quickly escalates, and the client becomes physically aggressive. Which intervention should the nurse implement first?
- A. Request a team member to assist with seclusion and restraint.
- B. Administer lorazepam 1.5 mg intramuscularly twice daily as needed.
- C. Confirm the client's identity and orientation to time and place.
- D. Inspect the area for objects that can be used in a dangerous manner.
- E. None.
- F. None.
Correct Answer: D
Rationale: Inspecting the area for dangerous objects is the first priority to ensure safety during the client's aggressive behavior.
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A client with opioid dependence makes a statement to the nurse about desiring to lead a healthier lifestyle by making changes in the next 2 weeks. How should the nurse respond?
- A. Support the client to list small behavioral changes needed.
- B. Explain the specific skills needed to prevent a relapse.
- C. Provide teaching on the symptoms of substance use dependence.
- D. Advise the client to reschedule until committing to recovery.
Correct Answer: A
Rationale: Supporting the client to list small behavioral changes is a person-centered approach that promotes achievable progress toward a healthier lifestyle.
An older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement?
- A. Tell the client to call Adult Protective Services if his son's abuse continues.
- B. Verify the client's report by determining if there is physical evidence of abuse.
- C. Refer the client to a program for victims of domestic violence.
- D. Assist the client in developing an emergency safety plan.
Correct Answer: D
Rationale: Assisting the client in developing an emergency safety plan is the most important intervention to ensure immediate safety in the context of ongoing abuse.
A client with generalized anxiety disorder (GAD) receives a new prescription for lorazepam. Which statement provided by the client requires additional instruction by the nurse?
- A. Use relaxation techniques to reduce excessive anxiety.
- B. Avoid alcohol and other sedatives while taking the medication.
- C. Move slowly from a sitting position to a standing position.
- D. Stop taking the medication if the intended effect is not immediate.
Correct Answer: D
Rationale: Stopping the medication if the effect is not immediate is incorrect, as lorazepam may take time to achieve full effect, and abrupt discontinuation can cause withdrawal.
A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit's day room. Which action should the nurse implement first?
- A. Sit in the chair next to the client.
- B. Listen to what the client is saying.
- C. Escort the client to his room.
- D. Administer a PRN sedative.
Correct Answer: B
Rationale: Listening to what the client is saying is crucial to understand the content and nature of the auditory hallucinations, guiding further interventions.
The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?
- A. Ask the client to describe the history of the injuries.
- B. Invite a colleague to document during the interview.
- C. Close the examination room door for privacy.
- D. Request hospital security to come to the department.
Correct Answer: C
Rationale: Closing the examination room door for privacy is the most appropriate action to create a confidential and secure environment for the client to discuss their injuries and provide a history, facilitating open communication.