A client on the mental health unit has been displaying signs of agitation, such as scowling and pacing rapidly up and down the hallway for several minutes.
Which behaviors should the nurse prioritize for monitoring?
Periodic sighing and shaking of the head.
Decreased activity level and change in affect.
Repeated requests for attention from the nurse.
Argumentativeness and use of profanity.
Correct Answer : A,C,D
Choice A rationale
Periodic sighing and shaking of the head can be signs of agitation and distress. These behaviors may indicate that the client is struggling to manage their emotions and may need additional support or intervention.
Choice B rationale
A decreased activity level and change in affect can be signs of many different mental health conditions, but they are not typically associated with agitation. Therefore, while these behaviors should be monitored, they are not the priority in this situation.
Choice C rationale
Repeated requests for attention from the nurse can be a sign of agitation. This behavior may indicate that the client is feeling distressed and is seeking help in managing their emotions.
Choice D rationale
Argumentativeness and use of profanity are clear signs of agitation. These behaviors can escalate quickly and may pose a risk to the safety of the client and others on the unit.
Therefore, these behaviors should be prioritized for monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Correct Actions:
Administer calcium as prescribed - Administering calcium (usually IV calcium gluconate) corrects the calcium deficiency, stabilizes nerve and muscle function, and helps stop or prevent further seizures.
Monitor respiratory status - Monitoring respiratory rate, effort, and oxygen saturation ensures early detection of hypoventilation, apnea, or oxygen desaturation.Maintaining airway and oxygenation is critical for safety and preventing hypoxia.
Correct Condition:
Hypocalcemia, or low calcium levels in the blood, can cause seizures in infants. Phenytoin, the medication given to the baby in the ambulance, is used to control seizures. Therefore, hypocalcemia could be the condition the infant is experiencing.
Correct Parameters to monitor:
Monitoring the respiratory rate is an important part of assessing any patient’s condition, especially an infant who has had a seizure.
Monitor serum calcium levels - Maintaining calcium within the normal neonatal range prevents recurrent seizures, cardiac arrhythmias, or neuromuscular irritability.
Correct Answer is C
Explanation
Choice A rationale
While taking the blood pressure in the other arm might avoid the spasms, it does not address the underlying cause of the spasms. Therefore, this is not the best action for the nurse to take.
Choice B rationale
Using a different sphygmomanometer would not necessarily prevent the spasms from occurring. The spasms are likely not caused by the equipment itself, but rather a physiological issue within the client.
Choice C rationale
The spasms in the client’s hand and fingers could be a sign of hypocalcemia, a condition where there is not enough calcium in the blood. One of the symptoms of hypocalcemia is muscle spasms or tetany. Therefore, reviewing the client’s serum calcium level would be an appropriate action to take.
Choice D rationale
Administering a PRN antianxiety medication would not address the underlying cause of the spasms. While anxiety can cause muscle tension and spasms, there is no indication in the scenario that anxiety is the cause of this client’s symptoms.
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