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
Hypoglycemia occurs when blood glucose levels drop below normal levels. It is commonly associated with diabetes mellitus and can result from various factors such as excessive insulin or oral hypoglycemic medication, delayed or missed meals, increased physical activity, or alcohol consumption.
Tremors, or shaking hands, are one of the early signs of hypoglycemia. They can occur due to the brain's response to low blood glucose levels. Other early signs of hypoglycemia may include sweating, palpitations, anxiety, hunger, and weakness.
A. Polyuria, or excessive urination, is not typically associated with hypoglycemia. It is more commonly seen in conditions such as hyperglycemia or diabetes insipidus.
C. Bradycardia, or a slow heart rate, is not a characteristic sign of hypoglycemia. It can occur in some cases of severe hypoglycemia, but it is not an early sign.
D. Difficulty swallowing is not directly related to hypoglycemia. It may be caused by other factors such as neurological or muscular conditions, esophageal disorders, or structural abnormalities in the throat or esophagus.
Correct Answer is ["C","D","E"]
Explanation
Prior to administering pain medication to an adult postoperative client, the practical nurse (PN) should obtain the following information:
- Time of last administration of pain medication: It is important to know when the client last received pain medication to ensure that the appropriate timing for the next dose is followed.
- Client's pain rating on a scale of 1 to 10: Assessing the client's current pain level helps determine the need for pain medication and the appropriate dose.
- Effectiveness of last pain medication administered: Evaluating the effectiveness of the previous pain medication helps determine if the current regimen is sufficient or if adjustments need to be made.
Obtaining the height and weight of the client prior to admission and the history of pain medication use during the past year may not be directly relevant to the immediate administration of pain medication.
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