A nurse in a mental health facility is caring for a client who becomes upset and breaks a chair when a visitor does not arrive. The client remains agitated following initial verbal attempts to calm him down. Which of the following interventions should the nurse implement first?
Plan with the client for how he can better handle frustration.
Place the client in a monitored seclusion room until he is calm.
Offer the client an antianxiety medication.
Restrain the client to prevent injury to himself or others.
The Correct Answer is C
A. Planning with the client for how he can better handle frustration is a valuable intervention, but it may not be immediately effective in the midst of heightened agitation. It is better suited for a calmer, more reflective time.
B. Placing the client in a monitored seclusion room until he is calm (option B) is an option for managing extreme agitation, but it should be used cautiously and as a last resort. Offering medication and attempting verbal de-escalation are generally preferable initial steps.
C. Offer the client an antianxiety medication.
When dealing with a client who is agitated and potentially escalating to a more volatile state, offering an antianxiety medication can be a helpful and immediate intervention to manage acute distress. It can aid in calming the client down and create an environment where other therapeutic interventions can be more effectively implemented.
D. Restraining the client to prevent injury to himself or others (option D) is a highly invasive intervention and should only be considered when there is an imminent risk of harm to the client or others. It is generally not the first choice in managing agitation due to its potential negative impact on the therapeutic relationship and the client's well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Neologism.
Neologism is a language disturbance in which the individual creates new, idiosyncratic words that have meaning only to the individual. In this case, the client's use of "mazuka" is an example of a neologism as it is a made-up word that holds significance only for the client.
B. Clang association involves the association of words based on sound rather than meaning.
C. Echolalia is the repetition of words or phrases spoken by others.
D. Word salad refers to a jumble of words and phrases that lack coherent meaning or logical connection.
Correct Answer is ["0.1"]
Explanation
To calculate the amount of haloperidol (in mL) that the nurse should administer, use the following formula:
Volume (mL)= Dose (mg)/Concentration (mg/mL)
In this case:
Volume (mL)=5 mg/50 mg/mL
Volume (mL)= 0.1 mL
Therefore, the nurse should administer 0.1 mL of haloperidol.
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