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 D

Explanation

"I might have trouble staying on a low-fat diet after my surgery." This statement, while relevant to postoperative care, is not a reason to delay obtaining the signature or notify the provider. The client's ability to adhere to a low-fat diet is a matter for preoperative education and counseling.

"I can resume my normal activities in 1 to 2 weeks." This statement, while reflecting the client's expectations for recovery, is not a reason to delay obtaining the signature or notify the provider. It indicates the client's understanding of the anticipated postoperative timeline.

"I will plan to be in the hospital for 24 hours following my surgery." This statement is incorrect as it relates to the type of surgery being performed (laparoscopic total cholecystectomy). Hospital stays for this procedure are typically shorter, often involving an overnight stay or even less. This discrepancy should be clarified with the provider before obtaining the signature.

"I hope that removing my appendix will make me feel better." This statement is incorrect and indicates a misunderstanding of the procedure. A laparoscopic total cholecystectomy involves the removal of the gallbladder, not the appendix. The nurse should delay obtaining the signature and notify the provider to ensure the client understands the correct procedure and its implications.

Correct Answer is ["38"]

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 is preparing to witness a client sign a consent for a laparoscopic total cholecystectomy. The nurse should delay obtaining the signature and notify the provider if the client makes which of the following statements?

Correct Answer is D

Explanation

Correct Answer is ["38"]

Explanation

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