A client is noted to be pacing on the unit with their hands clenched and mumbling curses. The nurse knows that the initial approach to this client would be to:
stop the client in the hall and tell them that they must pace in the day room instead.
keep hands in pockets so as not to appear threatening.
speak softly and calmly,
offer the client a cup of coffee.
The Correct Answer is C
a. Stop the client in the hall and tell them that they must pace in the day room instead. This can be confrontational and might escalate the situation.
b. Keep hands in pockets so as not to appear threatening. While non-threatening body language is important, the focus should be on verbal communication.
c. Speak softly and calmly. De-escalation is key in such situations. A calm and non-threatening approach is essential to build rapport and assess the situation.
d. Offer the client a cup of coffee. Stimulants like caffeine might worsen anxiety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. His wife has minimal family support: While limited family support might affect the caregiver’s burden, it does not directly imply immediate safety concerns for the client.
b. His wife works from home in telecommunication: Working from home can be beneficial as she is physically present to assist the client.
c. The client smokes one pack of cigarettes per day. Smoking increases the risk of cardiovascular events and other health complications, which can exacerbate symptoms of vascular NCD and pose safety risks.
d. The client has worked nightshift his entire life. While working night shifts might affect his sleep patterns, it does not pose an immediate safety concern compared to the risk associated with smoking.
Correct Answer is B
Explanation
a. Listen to the breath sounds in all lung fields: Assessing breath sounds is a more complex skill requiring a registered nurse's (RN) assessment.
b. Document the amount of output on the I & O sheet: Documenting intake and output (I&O) is a basic nursing task suitable for unlicensed nursing assistants (UNAs) under supervision.
c. Check the abdominal dressing for bleeding: Checking for bleeding requires a nurse's assessment due to the potential for complications.
d. Increase the IV fluid flow rate if the blood pressure is low: Adjusting IV fluids is a critical intervention requiring an RN's assessment and order.
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