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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?

A.

Instruct an unlicensed assistive personnel (UAP) to stay with the client.

B.

Notify the client's healthcare provider

C.

Administer an as needed (PRN) medication for agitation

D.

Escort the client to a calm and quiet place.

Answer and Explanation

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:

  1. 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.
  2. Notifying the client's healthcare provider is not a priority action, as it does not address the immediate safety of the client and others.
  3. 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.


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Related Questions

Correct Answer is B

Explanation

The infant has hypoglycemia, which is a low blood glucose level that can cause jitteriness, lethargy, seizures, or coma. Hypoglycemia is common in infants of mothers with gestational diabetes, as they produce excess insulin in response to high maternal glucose levels. The PN should begin frequent feedings of breast milk or formula, as this can provide a source of glucose and stimulate the infant's own glucose production.

The other options are not correct because:

A. Offering nipple feedings of 10% dextrose may be indicated in some cases of severe hypoglycemia, but it is not the first intervention. The PN should try oral feedings of breast milk or formula first, as they are more natural and less invasive.

C. Repeating the heel stick for glucose in one hour may be necessary to monitor the infant's glucose level, but it is not the first intervention. The PN should treat the hypoglycemia first, as it can have serious consequences if left untreated.

D. Assessing for signs of hypocalcemia may be important, as hypocalcemia is another possible complication in infants of mothers with gestational diabetes, but it is not the first intervention. The PN should address the hypoglycemia first, as it is more urgent and more likely to cause jitteriness.

Correct Answer is B

Explanation

This is the best response for the PN to provide because it sets a clear and firm boundary for the adolescent and discourages inappropriate or sexual comments. The PN should also redirect the adolescent's atention to another topic or activity and document the incident.

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