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
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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Related Questions
Correct Answer is C
Explanation
The client's provider cannot provide informed consent on behalf of the client. The provider's role is to explain the procedure, its risks and benefits, and answer any questions the client may have to help the client make an informed decision.
The client's mother may have a supportive role in the decision-making process, especially if the client desires their involvement. However, unless the client has been legally deemed unable to make decisions (for example, due to lack of decision-making capacity), the client's consent should be sought directly.
The client is the primary individual who should provide informed consent for their own medical procedure, assuming they have decision-making capacity. They have the right to accept or refuse the treatment after being fully informed about the procedure, risks, benefits, and alternatives.
The client's sibling does not have the authority to provide informed consent for the client's medical procedure unless they have been legally designated as the client's healthcare proxy or legally authorized decision-maker.
Correct Answer is C
Explanation
A. Providing the client's breakfast is an essential aspect of diabetes care, but obtaining information about the client's blood glucose level is a priority before administering insulin or making decisions about meal planning.
B. Obtaining the client's capillary blood glucose level is a critical first step. Knowing the current blood glucose level guides the nurse in determining the appropriate insulin dosage, assessing the need for any adjustments in the treatment plan, and planning the client's breakfast based on their current glucose level.
C. Checking the calibration of the glucometer is the first action to ensure the accuracy of the blood glucose measurement. Regular calibration checks help maintain the precision of the glucometer and ensure reliable results.
D. Administering prescribed insulin is an important step in managing type 1 diabetes, but the dosage should be determined based on the client's current blood glucose level. Administering insulin without knowing the current glucose level could lead to inappropriate dosage and potential complications.
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