A nurse enters the room of a client who becomes verbally abusive. Which of the following actions should the nurse take?
Remain a distance of 1 ft away from the client.
Speak slowly in a low, calm voice.
Forbid the client from speaking in an abusive manner.
Inform the client of consequences.
The Correct Answer is B
Choice A reason: Standing 1 ft away from a verbally abusive client is too close and may escalate the situation by invading their personal space. Maintaining a safe distance (about 3–6 ft) is recommended for safety.
Choice B reason: Speaking slowly in a low, calm voice helps de-escalate the situation by modeling calm behavior and reducing the client’s agitation. This approach promotes a safe environment and encourages de-escalation.
Choice C reason: Forbidding the client from speaking abusively may escalate their agitation, as it can be perceived as confrontational. A non-confrontational approach, like staying calm, is more effective.
Choice D reason: Informing the client of consequences may be appropriate later, but it is not the first action. De-escalation through calm communication is the priority to manage the immediate verbal abuse safely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:Cottage cheese is a low-tyramine food and generally safe for patients taking monoamine oxidase inhibitors (MAOIs) like phenelzine. It does not pose a significant risk of causing a hypertensive crisis, which is a concern with MAOIs due to their interaction with tyramine-rich foods.
Choice B reason:Shellfish is not typically high in tyramine, the compound that can cause dangerous interactions with MAOIs. While food safety (e.g., avoiding spoiled shellfish) is important, shellfish does not need to be avoided specifically due to phenelzine use.
Choice C reason:Salami, a cured meat, is high in tyramine, which can interact with MAOIs like phenelzine. This interaction can lead to a hypertensive crisis, characterized by dangerously high blood pressure, headaches, and other serious symptoms. Patients on MAOIs must avoid tyramine-rich foods like aged meats, cheeses, and fermented products.
Choice D reason:Frozen peas are not high in tyramine and do not pose a risk when taken with MAOIs. They are generally safe for consumption and do not require dietary restrictions for patients on phenelzine.
Correct Answer is A
Explanation
Choice A reason:Vomiting or diarrhea can lead to dehydration, which increases lithium levels in the blood, potentially causing toxicity. Instructing the client to notify their provider about these symptoms is critical for safe lithium use.
Choice B reason:Decreasing fluid intake to 1 liter per day is dangerous with lithium, as adequate hydration (typically 2–3 liters daily) is needed to prevent toxicity. This is incorrect advice.
Choice C reason:Excessive saliva is not a common side effect of lithium. More typical side effects include thirst, tremor, or weight gain, so this statement is inaccurate.
Choice D reason:Lithium can be taken with or without food, but taking it with food may reduce stomach upset. Advising it must be taken on an empty stomach is not necessary and could discourage adherence.
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