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 B
Explanation
The correct answer is choice B. Notify the charge nurse of the client's concerns about surgery. Choice A rationale:
Reminding the client that the consent has already been obtained does not address the client's current fears and uncertainty about undergoing the surgery. It may come across as dismissive and unsupportive of the client's emotional needs.
Choice B rationale:
This is the correct answer because notifying the charge nurse of the client's concerns about surgery allows the nursing team to provide the necessary support and address the client's emotional needs appropriately. The charge nurse can assess the client's anxiety level, discuss the procedure, and involve the healthcare provider if needed to ensure the client is well-
informed and comfortable with their decision. Choice C rationale:
Documenting the client's expressed concerns about the surgery is essential for accurate documentation but does not provide the immediate support and intervention the client may require.
Choice D rationale:
Encouraging the client to continue with the scheduled surgery without addressing their fears and uncertainty may not be appropriate. The client's emotional well-being should be a priority, and they should feel supported in their decision-making process.
Correct Answer is D
Explanation
The correct answer is choice D: Provide fluid and electrolyte replacement. Choice A rationale:
Isolating all infectious diarrhea victims is not the highest priority in this situation. While it is essential to prevent the spread of cholera, immediate medical intervention to treat those affected takes precedence.
Choice B rationale:
Administering prophylactic antibiotics as prescribed is not the highest priority because it focuses on prevention rather than treatment. In the case of a cholera outbreak, it is more critical to address the immediate needs of those already diagnosed.
Choice C rationale:
Administering cholera vaccines may be part of a preventive strategy, but it is not the highest priority during an active cholera outbreak. Vaccination takes time to develop immunity, and the focus should be on treating those already affected.
Choice D rationale:
Providing fluid and electrolyte replacement is the highest priority in managing cholera. Cholera is characterized by severe diarrhea and dehydration, which can lead to life-threatening complications. Promptly restoring fluids and electrolytes helps prevent shock and organ failure.
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