A nurse in a long-term care facility is monitoring clients in the day room. A client who has dementia becomes angry and starts screaming at the nurse. Which of the following interventions should the nurse take first?

Engage the client in a repetitive activity as a distraction.

Place the client in a seclusion room.

Apply wrist restraints to the client.

Administer PRN haloperidol IM to the client

Answer and Explanation

The Correct Answer is A

A. Engage the client in a repetitive activity as a distraction:

This is the correct answer. Redirecting the client's focus to a repetitive and calming activity can help distract them from the source of agitation and potentially de-escalate the situation.

B. Place the client in a seclusion room:

Seclusion should only be used in situations where it is absolutely necessary for the safety of the client or others. Placing a client with dementia in seclusion is not the first choice and should be avoided if possible.

C. Apply wrist restraints to the client:

Restraints should be a last resort and used only when there is an imminent risk of harm to the client or others. Restraints can escalate agitation and should not be the initial response.

D. Administer PRN haloperidol IM to the client:

The use of medication should be considered later in the escalation process and after other non-pharmacological interventions have been attempted. It is not the first intervention, especially when there are non-pharmacological options available.

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Correct Answer is C

Explanation

A. A client with schizophrenia exhibiting apathy may require attention, but it may not be an immediate priority unless there are signs of deterioration or safety concerns.

B. A client with an anxiety disorder appearing restless may be experiencing distress, but it is not necessarily indicative of an immediate safety or crisis situation.

C. A client with major depressive disorder reporting hopelessness raises significant concern, as it may indicate an increased risk of self-harm or suicide. Clients expressing hopelessness should be assessed promptly to determine the level of risk and implement appropriate interventions.

D. A client with bipolar disorder exhibiting provocative behavior may pose a potential risk, but the level of urgency is typically higher for a client expressing hopelessness and depressive

Correct Answer is ["38gtt\/min"]

Explanation

To calculate the IV flow rate in drops per minute (gtt/min), you can use the following formula:

Flow Rate (gtt/min)=(Volume (mL)/Time (min)) × Drop Factor (gtt/mL)

In this case:

Flow Rate = (150 mL/hr / 60 min/hr) × 15 gtt/mL

Flow Rate=37.5gtt/min

Therefore, the nurse should set the IV flow rate to deliver approximately 38 gtt/min for the dextrose 5% in water IV infusion at 150 mL/hr, rounded to the nearest whole number.

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A nurse in a long-term care facility is monitoring clients in the day room. A client who has dementia becomes angry and starts screaming at the nurse. Which of the following interventions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a mental health unit is caring for four clients. Which of the following clients should the nurse see first?

Correct Answer is C

Explanation

Correct Answer is ["38gtt\/min"]

Explanation

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