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. Changing the dressing is an action that comes after assessing and selecting the appropriate dressing. Before changing the dressing, the nurse needs to gather information and make decisions about the most suitable type of dressing based on the characteristics of the wound.

B. Selecting the appropriate dressing is an essential step, but before doing so, the nurse should review available dressing types to make an informed decision about which dressing will best meet the needs of the wound. This involves considering factors such as the wound's characteristics, exudate level, and the overall condition of the client.

C. Reviewing available dressing types is the first step because it allows the nurse to assess the wound, gather information about the client's condition, and make an informed decision about the most appropriate dressing. This step ensures that the chosen dressing aligns with the wound's characteristics and promotes optimal healing.

D. Documenting the dressing change is an important step in the process, but it typically occurs after the dressing change has been completed. Documentation is crucial for tracking the client's progress, ensuring continuity of care, and providing a record for other healthcare team members.

A. I should wait until I am terminally ill to complete my advance directives." B. "I must name a relative to make decisions for me in my health care proxy." C. I can state in my living will which medical treatments I want done if I am terminally ill." D. "I will make changes to my advance directives if I change my mind about anything." E. I will need to complete a new living will each time I am hospitalized."

Correct Answer is ["C","D"]

Explanation

A. "I should wait until I am terminally ill to complete my advance directives."

This statement is incorrect. It is advisable to complete advance directives before a critical or terminal illness occurs to ensure that one's preferences are known and respected in the event of incapacity.

B. "I must name a relative to make decisions for me in my health care proxy."

This statement is incorrect. While naming a relative is a common choice, individuals can choose any competent person as their healthcare proxy, and it does not have to be a family member.

C. "I can state in my living will which medical treatments I want done if I am terminally ill."

This statement is correct. A living will allows individuals to specify the medical treatments they wish to receive or avoid in the event they become terminally ill or incapacitated.

D. "I will make changes to my advance directives if I change my mind about anything."

This statement is correct. Advance directives are not permanent and can be changed or updated if the individual's preferences or circumstances change.

E. "I will need to complete a new living will each time I am hospitalized."

This statement is incorrect. Advance directives, including living wills, are generally not tied to a specific hospitalization. They remain in effect unless the individual chooses to update or change them.

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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

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Correct Answer is C

Explanation

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Correct Answer is ["C","D"]

Explanation

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