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 B
Explanation
This statement suggests that the client has found sources of emotional support and is relying on them to cope with the challenges posed by his prognosis. Acceptance of a prognosis often involves coming to terms with the reality of the situation and finding ways to manage the emotional and practical aspects of it. By acknowledging the support he has received from his faith and family, the client demonstrates a willingness to lean on these resources for strength and comfort.
The other statements do not necessarily reflect acceptance of the prognosis:
A. "I think I had this disease for a long time, but the doctor did not find it." This statement implies a sense of disbelief or frustration with the delay in diagnosing the disease, rather than acceptance of the prognosis itself.
C. "I understand this is a disease that occurs mostly in older men." While this statement shows some awareness of the disease, it does not necessarily indicate acceptance. It may simply reflect an understanding of the demographics of prostate cancer without addressing the client's personal feelings or coping mechanisms.
D. "I do not have any use for those who say this disease is going to win." This statement may indicate resistance or defiance towards the negative outlook associated with the disease. It suggests a desire to maintain a positive attitude but does not necessarily reflect a full acceptance of the prognosis and its implications.
Correct Answer is D
Explanation
A. C-reactive protein level:
C-reactive protein (CRP) is a marker of inflammation but does not specifically identify the causative organism of an infection. While elevated CRP can suggest infection or inflammation, it doesn't provide the necessary information for treatment.
B. Serum blood glucose (BG) level:
Serum blood glucose levels are important to monitor in diabetic patients because high glucose levels can impair healing and increase the risk of infection. However, it does not directly help identify the causative organism in this situation.
C. Serum albumin:
Serum albumin reflects nutritional status and can indicate malnutrition or poor wound healing. While it may be relevant for healing, it is not the most immediate test to evaluate for infection.
D. Culture for sensitive organisms:
Given the red, swollen wound with drainage and foul odor, a wound culture is the most appropriate first step to identify the specific infectious organism. This will guide the healthcare provider in selecting the most appropriate antibiotic treatment.
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