A client in the psychiatric unit's dayroom is becoming agitated, talking incessantly, and starting to yell and swear at the other clients. Which action should the practical nurse (PN) implement first?
Instruct an unlicensed assistive personnel (UAP) to stay with the client.
Administer an as needed (PRN) medication for agitation.
Notify the client's healthcare provider.
Escort the client to a calm and quiet place.
The Correct Answer is D
Moving the client away from the stimuli in the dayroom and providing a calm environment, it may help to de-escalate the situation and reduce agitation. This action prioritizes the well-being of the client and helps to maintain a safe and therapeutic environment for all individuals involved.
A. Administer an as-needed (PRN) medication for agitation: Administering medication should not be the first action taken in this situation. It is important to first assess the client's condition and attempt to de-escalate the situation through non-pharmacological means. Medication should be considered if other interventions are ineffective or if there is an immediate risk of harm to the client or others.
B. Notify the client's healthcare provider: While it may be necessary to notify the client's healthcare provider about the situation, it is not the first action that should be implemented. The immediate priority is to ensure the safety of the client and those around them by providing support and supervision.
C. Escort the client to a calm and quiet place: Escorting the client to a calm and quiet place can be a helpful intervention, but it may not be the first action to take. It is important to first address the immediate safety concerns and attempt to de-escalate the situation. Once the client is calm and cooperative, they can be escorted to a more suitable environment if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Acne is a common skin condition that often requires specialized treatment. While general skin care practices can help maintain healthy skin, the most appropriate recommendation for a 16-year-old client seeking treatment for acne is to refer them to a dermatologist.
Acne can have various underlying causes, and effective treatment often involves a tailored approach based on the individual's specific condition. Dermatologists are medical professionals specializing in skin health and are best equipped to assess and provide appropriate treatment options for acne.
Correct Answer is ["A","B","C","F","G"]
Explanation
Based on the given information, the statements that indicate the client's confusion is resolving are:
- Asks how long he has been in the hospital: This shows cognitive awareness and the ability to ask relevant and coherent questions.
- States he is hungry: This indicates a return to normal appetite and the ability to recognize and express basic needs.
- Recognizes his daughter: This demonstrates the ability to recognize and identify a familiar individual, suggesting an improved level of cognitive functioning.
- Oriented to time, place, and self: Being aware of the current time, location, and personal identity reflects an improved level of orientation and mental clarity.
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The statement "Drinking broth" does reflect the client's willingness and ability to consume food.
The following statements suggest ongoing confusion or potential issues:
- Clawing at the air: This behavior may indicate restlessness, agitation, or disorientation.
- Keeps trying to get out of bed to find the swimming pool: This behavior may indicate confusion or an altered perception of reality.
The statement "Oxygen saturation on 0.5L of 100%" provides information about the client's oxygen saturation level but does not specifically address the resolution of confusion.
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