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 C
Explanation
A. "A single dose of diazepam is unlikely to cause side effects" is not accurate. Diazepam, like any medication, can have side effects even with a single dose. Common side effects include drowsiness, dizziness, and muscle weakness.
B. "Grapefruit juice inactivates this medication" is not specifically true for diazepam. However, grapefruit juice can interact with certain medications by inhibiting their metabolism in the liver, leading to increased levels of the drug in the bloodstream. It's essential to check for specific drug interactions, but this statement is not a key consideration for diazepam.
C. "Diazepam can cause drowsiness" is an important piece of information to include because diazepam is a benzodiazepine medication that can have sedative effects. Alerting the client to the potential for drowsiness is crucial to prevent any safety issues, such as falls or accidents.
D. "Avoid foods that contain tyramine" is not relevant to diazepam. Tyramine is associated with certain foods and can be a concern with medications called monoamine oxidase inhibitors (MAOIs). Diazepam is not an MAOI, so this advice does not apply to its use.
Correct Answer is D
Explanation
A. "You may experience muscle cramping from the induced seizure." While muscle stiffness is possible, the term "muscle cramping" might not accurately describe the postictal state after ECT.
B. "The most common adverse effects of ECT are related to anesthesia." While anesthesia is used during ECT, the most common adverse effects are related to the ECT procedure itself, such as confusion, memory loss, and headache.
C. "You should expect to have ECT once per week for 6 weeks." The frequency and duration of ECT treatments vary based on the individual's response and treatment plan. This statement provides a specific schedule that may not apply to all patients.
D. "You might feel a bit confused and disoriented when you first wake up." This statement accurately reflects a common and expected postictal effect of ECT. Patients undergoing ECT commonly experience confusion and disorientation upon awakening. This is a temporary and expected side effect of the treatment. It's important for the patient to be aware of this possibility as part of the informed consent process.
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