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 A
Explanation
Glaucoma is a group of eye diseases that damage the optic nerve and cause vision loss. It is often associated with increased intraocular pressure, which can compress the nerve fibers and reduce blood flow to the retina. The most common type of glaucoma, open-angle glaucoma, causes gradual loss of peripheral vision.
The other options are not correct because:
- Macular edema is a condition that causes swelling and fluid accumulation in the macula, the central part of the retina that is responsible for sharp and detailed vision. It can cause blurred or distorted vision, but it does not affect the optic nerve or the peripheral vision.
- Cataract is a condition that causes clouding of the lens, which is the transparent structure that focuses light onto the retina. It can cause blurred, dim, or yellowed vision, but it does not affect the optic nerve or the intraocular pressure.
- Diabetic retinopathy is a complication of diabetes that damages the blood vessels in the retina and causes bleeding, leakage, or scarring. It can cause blurred, fluctuating, or darkened vision, but it does not affect the optic nerve or the intraocular pressure.
Correct Answer is C
Explanation
This is the most important information for the PN to ask because it assesses the client's risk for self-harm and suicidal ideation. The client's statements indicate hopelessness, low self-esteem, and impaired functioning, which are potential warning signs of suicide. The PN should ask the client directly about any thoughts or plans of harming themselves and provide support and safety measures as needed.
A. Questioning about which rituals are most often used to reduce anxiety is not a priority and may reinforce the client's compulsive behavior.
B. Asking if the obsessions and compulsions interfere with sleep is not a priority and may not address the client's emotional distress.
D. Determining what makes the client think people are laughing is not a priority and may not be helpful for the client's perception of reality.
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