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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is the finding that the PN should instruct the postpartum client to report to the charge nurse because it may indicate an infection, such as endometritis, mastitis, or urinary tract infection, that requires prompt treatment.
The PN should also instruct the client to monitor for other signs of infection, such as foul-smelling lochia, redness or tenderness of the breasts, or dysuria.
Correct Answer is B
Explanation
Choice A rationale:
Crushing the medication and administering it in applesauce might alter its pharmacokinetics, rendering it ineffective or causing it to act too quickly. Sublingual tablets are designed to dissolve under the tongue for rapid absorption into the bloodstream. Crushing the tablet and mixing it with applesauce could change its intended mode of action.
Choice B rationale:
Placing the tablet under the client's tongue is the correct action for a sublingual tablet. Sublingual administration allows the medication to dissolve directly into the bloodstream through the sublingual mucosa, bypassing the digestive system and providing rapid onset of action.
Choice C rationale:
Obtaining a liquid form of the medication might be an option, but it may not always be available. Additionally, some medications are not available in liquid forms, and the liquid form might have a slower onset of action compared to the sublingual route.
Choice D rationale:
Placing the tablet inside the client's cheek is known as the buccal route of administration. While this route is also for oral absorption, sublingual administration is preferred for specific medications designed for rapid absorption.
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