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.
Notify the client's healthcare provider
Administer an as needed (PRN) medication for agitation
Escort the client to a calm and quiet place.
The Correct Answer is D
d. Escort the client to a calm and quiet place.
The PN should use a calm and firm approach to de-escalate the situation and remove the client from the stressful environment. This can help prevent further agitation and potential violence.
The other options are not correct because:
- Instructing a UAP to stay with the client may not be effective or safe, as the UAP may not have the skills or training to handle an agitated client.
- Notifying the client's healthcare provider is not a priority action, as it does not address the immediate safety of the client and others.
- Administering a PRN medication for agitation may be indicated, but it is not the first action. The PN should try non- pharmacological interventions first, unless there is an imminent risk of harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Urinary output is not directly related to stomatitis, which is inflammation of the mouth and throat. While monitoring urinary output is important in many situations, it is not relevant in this case.
Choice B rationale:
Blood pressure while standing is not directly related to stomatitis either. This assessment is more relevant for conditions such as orthostatic hypotension, which can cause a drop in blood pressure upon standing.
Choice C rationale:
Ability to swallow is crucial in the context of stomatitis. Stomatitis can cause painful sores in the mouth, making it difficult for the client to eat or drink. Assessing the client's ability to swallow will help determine the impact of stomatitis on their nutritional intake and overall well-being.
Choice D rationale:
Frequency of bowel movements is unrelated to stomatitis. This assessment is more relevant for gastrointestinal issues or constipation, not for a condition affecting the mouth and throat.
Correct Answer is A
Explanation
Circumoral cyanosis is a bluish discoloration around the mouth that indicates inadequate oxygenation. It is an abnormal finding in a full-term newborn and requires immediate assessment and intervention by the PN.
The other options are not correct because:
- A positive Babinski's reflex is a normal finding in newborns that indicates intact neurological function. It is elicited by stroking the sole of the foot and observing the fanning of the toes.
- A negative Ortolani's sign is a normal finding in newborns that indicates no hip dislocation or dysplasia. It is elicited by abducting the hips and feeling for any clicking or clunking sensation.
- A large sacral "stork bite" is a common benign birthmark that appears as a reddish patch on the lower back or nape of the neck. It usually fades within the first year of life and does not require any treatment.
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