Nokea
When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, 'What took you so long to get in here!' Which action should the nurse implement?
- A. Request backup from the staff.
- B. Stand in the doorway.
- C. Provide for personal space.
- D. Encourage the client to sit down.
Correct Answer: C
Rationale: Providing personal space reduces the perception of threat, helping de-escalate agitation safely.
You may also like to solve these questions
Laboratory Results
Vital signs
The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and was recently diagnosed with end-stage renal disease (ERSD). She has been placed on hemodialysis three times a week for one month. She presents to the emergency department (ED) with fatigue, generalized weakness, muscle cramps, tingling sensation in her arms and legs, and lightheadedness following 3 days of Illness during which her husband reports she has complained of nausea and had a poor appetite and was not able to go for her scheduled dialysis 2
What treatments should the nurse anticipate for the client at this time? Select all that apply.
- A. Call and give a report immediately
- B. Administer loop diuretic
- C. Schedule for Hemodialysis immediately
- D. Check blood glucose level
- E. Draw a repeat potassium level
- F. Hold Lisinopril
- G. Administer insulin, dextrose 50%, and calcium gluconate. Then repeat 12 lead EKG
Correct Answer: C,D,E,F,G
Rationale: Hemodialysis, checking glucose, repeating potassium, holding Lisinopril, and administering insulin/dextrose/calcium gluconate address hyperkalemia and ESRD complications. Loop diuretics are contraindicated, and reporting is not a treatment.
A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?
- A. Concentrate on and ventilate emotions when distressed.
- B. Shift attention from self to the needs and requests of others.
- C. Relax and reduce the amount of effort to solve the problem.
- D. Focus on small achievable tasks, not taxing problems.
Correct Answer: D
Rationale: Focusing on small achievable tasks can reduce feelings of overwhelm and improve self-efficacy in a client with depression. Ventilating emotions may exacerbate distress, shifting attention may neglect personal needs, and relaxation may perpetuate helplessness.
The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?
- A. Explore changes in life that have occurred after the loss.
- B. Suggest the need for a psychiatric consultation.
- C. Offer a referral to pastoral counseling.
- D. Encourage attending a local support group.
Correct Answer: A
Rationale: Exploring life changes post-loss helps assess the client's grief and tailor interventions, making it the priority action.
The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?
- A. Cancer screening results, anger, gastritis, daily alcohol intake.
- B. Consumption, liver enzyme, gastrointestinal complaints, and bleeding.
- C. Efforts to cut down, annoyance with questions, guilt, and drinking as an 'Eye-opener.'
- D. Minimizes drinking, frequently misses family events, guilt about drinking, and amount of daily intake.
Correct Answer: C
Rationale: The CAGE questionnaire assesses alcohol dependency through efforts to cut down, annoyance, guilt, and eye-opener drinking, which should be explored in-depth.
Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?
- A. Any history of heart disease.
- B. Familial history of mental illness.
- C. Current weight.
- D. Medication history.
Correct Answer: D
Rationale: Medication history is critical to identify potential drug interactions, especially with serotonergic drugs, to prevent serotonin syndrome. Heart disease history, familial mental illness, and weight are relevant but secondary. [Note: Document incorrectly lists A as correct; D is more appropriate per standard practice.]