A newly admitted patient in an acute manic state has a nursing diagnosis of at risk for injury related to hyperactivity. Which nursing intervention is most appropriate?
Have the patient sit in his room while you review all the rules of the unit.
Reinforce previously learned coping mechanisms to calm the patient down.
Place the patient in a room with another hyperactive patient.
Administer antipsychotic medication as ordered and as needed by the physician.
The Correct Answer is D
Choice A reason: Having the patient sit alone while reviewing rules does not address the immediate risk of injury due to hyperactivity.
Choice B reason: Reinforcing coping mechanisms can help the patient manage hyperactivity and reduce the risk of injury.
Choice C reason: Placing the patient with another hyperactive patient could potentially exacerbate the situation and increase the risk of injury.
Choice D reason: While administering medication may be necessary, it should be done in conjunction with other interventions that address behavior management.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Ensuring safety is important, but it does not directly address the immediate risk of suicide as effectively as understanding the client's intentions.
Choice B reason: Informing the provider is a critical step, but it should follow after assessing the immediate risk to the client's safety.
Choice C reason: Questioning the client about a suicide plan and method is the most immediate and direct way to assess the risk of suicide and take appropriate safety measures.
Choice D reason: Administering medication is important for managing anxiety but does not take precedence over assessing the risk of suicide in a client expressing such thoughts.
Correct Answer is C
Explanation
Choice A reason: This statement is not appropriate as it may sound condescending and does not acknowledge the client's effort in a respectful manner.
Choice B reason: This question could be perceived as intrusive and might make the client feel defensive about their self-care activities.
Choice C reason: This response is appropriate as it is a neutral observation that acknowledges the client's effort without making judgments or assumptions.
Choice D reason: While this statement is positive, it may not be the best choice as it could be interpreted as patronizing rather than a simple acknowledgment.
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