A nurse is assisting in the care of a client in a mental health facility. During group therapy, the client stands up and starts pacing with their fists clenched. Which of the following actions should the nurse take first?
Administer haloperidol via the intramuscular route.
Collect data regarding the client's feelings.
Obtain assistance to apply wrist restraints.
Move the client into the seclusion room.
The Correct Answer is B
Rationale:
A. Administer haloperidol via the intramuscular route: Medication may be necessary for agitation, but administering it before assessing the client’s emotional state and safety is premature and could escalate distress.
B. Collect data regarding the client’s feelings: Assessing the client’s emotional state and reasons for pacing and clenched fists helps identify triggers, enabling the nurse to choose the least restrictive intervention and promote de-escalation.
C. Obtain assistance to apply wrist restraints: Restraints are a last resort to ensure safety and should only be used after less restrictive interventions have failed and when the client poses an immediate risk to self or others.
D. Move the client into the seclusion room: Seclusion is also a restrictive intervention requiring assessment of necessity. Moving the client without first gathering data and attempting de-escalation may violate client rights and worsen agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
Rationale:
• Suicidal ideation: The client has a history of suicidal threats and is currently expressing distress, isolation, and a desire to no longer exist. These are key red flags for suicidal thoughts and require immediate monitoring.
• Hopelessness: Statements like “I wish I weren’t here” and “my life is a mess” indicate a loss of hope about the future. Hopelessness is a strong predictor of suicidal intent in clients with depression.
• Acute stress disorder: This condition involves exposure to a traumatic event within the past month with symptoms like flashbacks or dissociation. The client’s distress stems from life changes, not acute trauma.
• Borderline personality disorder: While this disorder includes unstable relationships and emotional reactivity, there is no history of impulsivity or identity disturbance to support the diagnosis.
• Emotional lability: The client displays a flat affect and tearfulness, not rapid mood shifts. Emotional lability refers to quick and exaggerated changes in emotional expression.
• Hypervigilance: This involves a heightened state of alertness often associated with trauma or PTSD. The client’s behavior is more aligned with withdrawal and depression.
Correct Answer is C
Explanation
Rationale:
A. Chlorhexidine: Chlorhexidine is primarily used as an antiseptic for skin preparation or wound cleaning. It is not effective for disinfecting surfaces contaminated with bloodborne pathogens such as HIV.
B. Hydrogen peroxide: While hydrogen peroxide has disinfectant properties, it is less effective than bleach against a broad range of viruses, especially in situations involving blood spills where a higher-level disinfectant is recommended.
C. Bleach: A 1:10 dilution of household bleach (sodium hypochlorite) is the recommended solution for disinfecting surfaces contaminated with blood due to its strong virucidal properties. It effectively kills HIV and other bloodborne pathogens on environmental surfaces.
D. Isopropyl alcohol: Isopropyl alcohol has limited effectiveness against organic matter like blood and is not recommended for disinfecting blood-contaminated surfaces. It evaporates quickly and may not provide adequate contact time for complete disinfection.
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