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 B
Explanation
a. Diphenhydramine: Diphenhydramine is an antihistamine that can also be used for its sedative properties to help calm an agitated client.
b. Ondansetron: Ondansetron is an antiemetic used to prevent nausea and vomiting, not for managing agitation or assaultive behavior. The nurse should question this order as it is not appropriate for the client's current symptoms.
c. Lorazepam: Lorazepam is a benzodiazepine used for its anxiolytic and sedative effects, making it appropriate for calming an agitated client.
d. Haloperidol: Haloperidol is an antipsychotic medication commonly used to manage severe agitation and aggressive behavior.
Correct Answer is A
Explanation
a. Assist the client with bathing and toileting. This intervention addresses the client's immediate and essential needs. Ensuring basic hygiene and toileting are crucial for maintaining the client's health, dignity, and comfort. Assisting with activities of daily living (ADLs) is a priority for clients who are unable to perform these tasks independently.
b. Design a bulletin board to represent the current season. While this can help with orientation and provide a sense of time and place, it is not as critical as addressing the client's basic physical needs.
c. Present evidence of objective reality to improve cognition. Reality orientation can be beneficial, but it is not a priority intervention compared to meeting the client's immediate physical needs.
d. Label the door to the client's room with name and number. This helps with orientation and independence but is less critical than ensuring the client’s hygiene and toileting needs are met.
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