A nurse in an acute care mental health facility is sitting with a group of clients in a meeting room. A client suddenly jumps up and begins yelling angrily. Which of the following actions should the nurse take to ensure environmental safety?

Give the client more than one choice for resolving the conflict.

Move toward the client using an aggressive stance.

Choose two staff members to represent the staff and speak to the client.

Stand between the client and the doorway of the room.

Answer and Explanation

The Correct Answer is D

A. Give the client more than one choice for resolving the conflict. While providing choices can be beneficial in some situations, it is not a direct action to ensure immediate environmental safety when a client is escalating aggressively.
B. Move toward the client using an aggressive stance. This approach is inappropriate and can escalate the situation further. A calm and non-threatening demeanor is essential in managing an aggressive client.
C. Choose two staff members to represent the staff and speak to the client. Having multiple staff members engage with an agitated client can sometimes help, but it’s crucial that any interaction is done calmly and without escalating the situation.
D. Stand between the client and the doorway of the room. This is the most appropriate action to ensure safety. Positioning yourself between the client and the exit can prevent the client from leaving the room and potentially harming themselves or others while ensuring a safe space to de-escalate.

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Correct Answer is A

Explanation

A. "If I continue to breathe in carbon monoxide, I could become unconscious." This is correct. Continued exposure to carbon monoxide can lead to unconsciousness and even death.
B. "If there is carbon monoxide in my house. I'll be able to smell it." This is incorrect. Carbon monoxide is a colorless and odorless gas, making it impossible to detect by smell.
C. "I have a gas furnace, so I don't have to worry about carbon monoxide." This is incorrect. Gas furnaces can produce carbon monoxide, especially if they are not properly ventilated or maintained.
D. "I will change the battery in my carbon dioxide detector every 2 years." This is incorrect. The batteries in carbon monoxide detectors should be changed more frequently, typically every 6-12 months, to ensure they function properly.

A. Elevated blood pressure B. Decreased heart rate C. Report of epigastric pain D. Mental confusion

Correct Answer is D

Explanation

A. Elevated blood pressure This is not a common manifestation of a UTI in older adults.
B. Decreased heart rate This is not associated with UTIs.
C. Report of epigastric pain Epigastric pain is more related to gastrointestinal issues.
D. Mental confusion Older adults with UTIs often present with mental confusion or altered mental status, rather than the classic symptoms seen in younger individuals.

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A nurse in an acute care mental health facility is sitting with a group of clients in a meeting room. A client suddenly jumps up and begins yelling angrily. Which of the following actions should the nurse take to ensure environmental safety?

Nursing Test Bank

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