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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Fidelity refers to the concept of keeping promises or commitments made to clients. In this scenario, the nurse is demonstrating fidelity by informing the client that they will return as soon as possible with pain medication, indicating a commitment to addressing the client's needs promptly.

B. Justice pertains to fairness and equitable distribution of resources. It is not demonstrated in this scenario where the nurse is making a commitment to address the client's pain.

C. Autonomy involves respecting the client's right to make their own decisions and choices about their care. The nurse, in this case, is not specifically addressing the client's autonomy but rather demonstrating fidelity by committing to providing pain medication.

D. Nonmaleficence is the principle of doing no harm and ensuring the client's safety. While providing pain medication aligns with nonmaleficence by addressing the client's pain, the specific action of informing the client about the intent to return promptly falls more under the principle of fidelity.

A. A staff member places a midstream urine sample in a specimen refrigerator after-collecting it. B. A staff member wipes a countertop with chlorhexidine solution to clean the area following a blood spill. C. A nurse uses alcohol-based antiseptic to clean his hands after talking with a client who has varicella zoster. D. A nurse pours sterile 0.9% sodium chloride irrigation solution on an open pressure wound prior to collecting a specimen for culture

Correct Answer is C

Explanation

A. A staff member places a midstream urine sample in a specimen refrigerator after collecting it: This action is appropriate as long as the specimen is labeled correctly and stored at the correct temperature. Proper handling of specimens is essential for accurate testing and does not represent an infection control hazard.

B. A staff member wipes a countertop with chlorhexidine solution to clean the area following a blood spill: This action is appropriate for cleaning a contaminated surface. Chlorhexidine is an effective disinfectant for blood spills. Therefore, this action does not represent an infection control hazard.

C. A nurse uses alcohol-based antiseptic to clean his hands after talking with a client who has varicella zoster: While alcohol-based antiseptics are effective for most pathogens, varicella zosteris primarily spread through direct contact and airborne transmission. It is recommended to wash hands with soap and water after caring for a patient with varicella zoster, especially if hands are visibly soiled. This action may not adequately control the infection hazard.

D. A nurse pours sterile 0.9% sodium chloride irrigation solution on an open pressure wound prior to collecting a specimen for culture: This action is appropriate as long as sterile technique is maintained. Using sterile saline for irrigation is standard practice to minimize the risk of introducing pathogens before specimen collection. Therefore, this action does not represent an infection control hazard.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 collecting data from a client who is experiencing abdominal pain. The nurse states that they will return as soon as possible with pain medication. The nurse is demonstrating which of the following ethical principles?

Correct Answer is A

Explanation

A nurse at a long-term care facility is assisting with teaching staff about infection control practices. Which of the following examples should the nurse include as an infection control hazard?

Correct Answer is C

Explanation

A nurse is documenting the care of a client in the computer when she is called to another client's room. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with the family of an older adult client about safety precautions. Which of the following recommendations should the nurse include to reduce the risk of a client fall? (Select all that apply.)

A nurse is preparing to administer a medication to a client and discovers that the incorrect dose of medication was administered during the previous shift. Which of the following actions should the nurse take first?

A nurse is preparing to administer an intermittent enteral feeding through a small-bore NG tube. Which of the following actions should the nurse take before initiating the feeding?

A nurse is preparing to administer morphine 7.5 mg subcutaneous. Available is morphine injection 10 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.)

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?

A charge nurse is reinforcing teaching with a newly licensed nurse about methods to contain health care costs within the acute care facility. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A nurse is reinforcing teaching with a group of older adults about collecting home supplies for disaster situations. Which of the following Information should the nurse include in the teaching?