A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?
Document the client's behavior every 15 min.
Obtain the provider's prescription within 60 min.
Monitor the client's vital signs every 4 hr.
Offer the client food and fluids every 2 hr.
The Correct Answer is A
A. Documenting the client's behavior every 15 minutes is essential for monitoring the client's condition, response to seclusion, and any changes in behavior or status.
B. Obtaining the provider's prescription within 60 minutes may be necessary but does not address immediate nursing actions required after placing the client in seclusion.
C. Monitoring vital signs every 4 hours is not specific to managing a client in seclusion and may not provide timely information about the client's condition or response to seclusion.
D. Offering food and fluids every 2 hours is important for meeting the client's physiological needs but may not be appropriate immediately after placing the client in seclusion, depending on the circumstances and facility policies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
First, we need to determine how many milligrams (mg) are in each milliliter (mL) of the solution.
The available methylphenidate oral solution has a concentration of 10 mg per 5 mL.
To find out how many milligrams are in 1 mL of the solution, we divide 10 mg by 5 mL: 10 mg / 5 mL = 2 mg/mL
The child's prescription is for 40 mg per day, divided into two doses. So, each dose should contain:
40 mg / 2 doses = 20 mg per dose 2mg=1ml
20mg= 20*1/2= 10ml
Therefore, the nurse should administer 10 mL of methylphenidate oral solution per dose
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"A"},"H":{"answers":"A"}}
Explanation
Electroconvulsive therapy (ECT) is contraindicated in the acute phase of alcohol withdrawal due to the increased risk of seizure activity.
Group therapy is anticipated as it can provide peer support, coping strategies, and psychoeducation, which are beneficial for individuals with alcohol use disorder.
Performing the Alcohol Use Disorders Identification Test (AUDIT) is anticipated to assess the severity of alcohol use disorder and guide treatment planning.
Methadone may be anticipated as part of the treatment plan for managing alcohol withdrawal symptoms and cravings.
Ordering a complete blood count and basic metabolic profile is anticipated to assess the client's overall health status and detect any abnormalities related to alcohol use.
A nutritional consult is anticipated to address the client's weight loss and minimal appetite, providing dietary recommendations and support.
Propranolol may be anticipated to manage autonomic symptoms of alcohol withdrawal, such as tremors and tachycardia.
Diazepam may be anticipated to manage alcohol withdrawal symptoms, including agitation, anxiety, and seizures.
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