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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Adult day care is a service that provides care and supervision to adults who need assistance during the day, often due to physical or cognitive impairments. However, it may not be specifically geared toward providing wound care services.
B. Long-term care typically involves comprehensive, ongoing assistance with activities of daily living for individuals who have chronic illnesses or disabilities. While wound care may be part of long-term care, it's not the primary focus, and it is often provided in various settings, including home care.
C. Wound care is the most appropriate recommendation for an older adult client requiring dressing changes for a healing pressure ulcer. This service may include home health nursing visits to perform the necessary wound care, monitor healing progress, and provide education to the client and their caregivers.
D. Palliative care is focused on providing relief from the symptoms and stress of a serious illness, and it can be appropriate for clients with chronic conditions. However, in this scenario, the primary need is for wound care rather than palliative care.
Correct Answer is ["0.75"]
Explanation
To calculate the volume (mL) that the nurse should administer, you can use the following formula:
Volume (mL) = Dose (mg)/Concentration (mg/mL)
In this case:
Volume=7.5 mg/10 mg/mL
Volume=0.75mL
Therefore, the nurse should administer 0.75 mL of morphine for the 7.5 mg subcutaneous dose, rounded to the nearest hundredth.
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