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. "The surgeon can obtain informed consent from the client's adult cousin."Informed consent must be obtained from a parent or legal guardian for a minor. An adult cousin does not have the legal authority to provide consent unless they are the legal guardian of the minor, which is not indicated in this scenario.

B. "The surgeon should delay surgery until he can obtain informed consent from a parent."Delaying surgery in an emergency situation could endanger the client's life or health. In such cases, waiting for parental consent is not advisable, and other legal mechanisms, such as implied consent, should be used to proceed with necessary treatment.

C. "The surgeon can proceed with the surgery by invoking implied consent."In emergency situations where the client is a minor and the parents or legal guardians are not available to provide consent, the principle of implied consent allows healthcare providers to perform life-saving procedures without explicit consent. The law recognizes that in emergencies, delaying treatment to obtain consent could result in harm, so the surgeon can proceed with the surgery.

D. "The client's pediatrician can obtain implied consent."The concept of implied consent is not something that can be "obtained" by another healthcare provider. It is a legal principle that allows healthcare providers to act in the best interest of the client during an emergency when consent cannot be obtained. The pediatrician does not have a role in obtaining or invoking implied consent in this context; it is the responsibility of the surgeon performing the emergency procedure.

Correct Answer is ["2.1"]

Explanation

To calculate the total daily dose of tobramycin, we use the formula:

Total Daily Dose (mg) = Dose (mg/kg/day) × Weight (kg)
Total Daily Dose (mg)=Dose (mg/kg/day)×Weight (kg)

In this case:

Total Daily Dose=3 mg/kg/day × 85 kg
Total Daily Dose=255mg/day

Since the total daily dose is divided into three doses, the nurse should administer:

Dose per Administration =Total Daily Dose/Number of Doses per Day
Dose per Administration = 255 mg/3
Dose per Administration≈85mg

Now, to calculate the volume (mL) to administer, we use the concentration of the available tobramycin solution:

Volume (mL)=Dose per Administration (mg)/Concentration (mg/mL)

In this case:

Volume=85mg/40mg/mL
Volume≈2.1mL

Therefore, the nurse should administer approximately 2.1 mL of tobramycin per dose, rounded to the nearest tenth.

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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 caring for a 16-year-old client who was in a motor-vehicle crash and needs surgical intervention immediately. The staff cannot reach either of the client's parents. The nurse should identify that which of the following is true about obtaining consent?

Correct Answer is C

Explanation

Correct Answer is ["2.1"]

Explanation

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