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.
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Related Questions
Correct Answer is D
Explanation
When a client's family member expresses concerns about the care provided, it is essential for the nurse to gather more information and understand the specific issues raised. By asking for a description of what happened during the night, the nurse can obtain details about the perceived inadequate care. This allows the nurse to gather accurate information, assess the situation, and address any legitimate concerns.
A. Explaining that all staff are doing their best may not address the specific issues raised by the daughter and may not provide a satisfactory resolution to her concerns.
B. Telling the daughter to talk with the unit's nurse manager can be an appropriate step, but it should come after gathering information about the situation. The nurse needs to have a clear understanding of what happened before involving the nurse manager.
C. Reassuring the daughter that the mother will get better care may not address her concerns and may not provide a solution to the perceived problem. It is important to gather more information before offering reassurance or making promises.
Correct Answer is B
Explanation
After a hip arthroplasty with prosthesis placement, it is important to follow specific precautions to protect the surgical site and prevent dislocation of the hip joint. One common precaution is to avoid excessive internal rotation, adduction, and f
The other observations mentioned in the scenario are correct and demonstrate appropriate knowledge of the turning procedure:
A. Placing an abduction pillow between the client's legs helps maintain proper alignment and prevents adduction of the legs, which can cause hip dislocation.
C. Keeping the back straight and knees bent when moving the client promotes proper body mechanics and reduces the risk of injury to the UAPs.
D. Using a turning sheet under the client for turning and repositioning helps reduce friction and shearing forces, making the process safer and more comfortable for the client.
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