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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 correct answer is choice B. Attach the drainage bag to the bed frame.

Choice A rationale:

Measuring the urinary output in the bag is a routine task but does not address the improper placement of the drainage bag. The immediate concern is to ensure the drainage bag is correctly positioned to prevent complications.

Choice B rationale:

Attaching the drainage bag to the bed frame is the correct action. The drainage bag should be kept below the level of the bladder and attached to a non-movable part of the bed to prevent backflow and reduce the risk of infection.

Choice C rationale:

Applying gloves and emptying the drainage bag is not the immediate priority. The drainage bag should not be allowed to overfill, but in this scenario, it is only half-full, so this action is not urgent.

Choice D rationale:

Removing the looped tubing from the bed is important to ensure proper drainage and prevent backflow, but it does not address the incorrect placement of the drainage bag, which is the primary concern in this situation.

Correct Answer is B

Explanation

Ask the client to describe what happened.

Calling the agency-based client advocate (Choice A) should not be the first action taken in this situation. While involving an advocate might be necessary at some point, it is more appropriate to address the client's concerns and gather information about the incident first.

Completing a client adverse incident report (Choice C) is an important step to document theevent and any potential issues, but it should not be the first action taken. Before completing the report, the nurse needs to understand the situation from the client's perspective.

Informing the charge nurse of the situation (Choice D) is a reasonable step, but it should not be the first action. It may be necessary to escalate the issue, but understanding the situation from the client's viewpoint should be prioritized.

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