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. Disinfecting hands using an alcohol-based waterless antiseptic is not effective against Clostridium difficile spores. C. difficile is a bacterium that forms spores, which are resistant to alcohol-based hand sanitizers. Handwashing with soap and water is recommended for effective removal of the spores.

B. Wearing an N95 respirator is not specifically indicated for caring for clients with Clostridium difficile. The primary mode of transmission for C. difficile is fecal-oral, and standard precautions, including gloves and gowns, are usually sufficient. N95 respirators are more commonly used for airborne precautions.

C. Using diluted bleach to clean soiled equipment is the correct instruction. Clostridium difficile spores are resistant to many disinfectants, but bleach (sodium hypochlorite) is effective in killing C. difficile spores. Diluted bleach solutions are recommended for cleaning surfaces and equipment that may be contaminated with C. difficile.

D. Providing a room with negative-pressure airflow is not typically necessary for clients with Clostridium difficile. Standard precautions, including appropriate cleaning and disinfection, are generally sufficient to prevent the spread of C. difficile in healthcare settings.

A. Facility policy and procedure manual B. Poison Control Center C. Safety data sheet D. The National Quality Forum

Correct Answer is A

Explanation

A. Facility policy and procedure manual.

The facility policy and procedure manual is the primary resource for step-by-step directions to clean up a chemical spill within a specific healthcare setting. Each healthcare facility has its own policies and procedures outlining the appropriate steps to take in the event of a chemical spill to ensure the safety of both patients and healthcare providers.

B. Poison Control Center:

The Poison Control Center is a valuable resource for information related to poisoning, but it may not provide specific step-by-step directions for cleaning up a chemical spill. Its primary focus is on managing exposures and providing advice on the treatment of poisonings.

C. Safety data sheet (SDS):

The Safety Data Sheet provides information about the properties of a chemical substance. While it offers details about the chemical and its hazards, it is not typically used as a step-by-step guide for cleaning up a spill. The SDS is more focused on providing information about the chemical's properties, safety precautions, and emergency response measures.

D. The National Quality Forum:

The National Quality Forum is a healthcare organization that focuses on healthcare quality improvement. It is not a primary resource for specific step-by-step directions for handling a chemical spill. Facility-specific policies and procedures are more appropriate for this purpose.

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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

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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