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 B
Explanation
Rationale:
A. Use an N95 respirator: N95 respirators are necessary for airborne precautions, such as with tuberculosis or measles. C. difficile is transmitted via contact with contaminated surfaces or stool, not airborne particles, so an N95 is not indicated.
B. Initiate contact precautions: Contact precautions are required for C. difficile because it spreads through direct and indirect contact with contaminated surfaces or stool. Gloves and gowns should be worn, and hand hygiene with soap and water is essential to prevent spore transmission.
C. Place the child in a room that has a HEPA filtration system: HEPA filters are used for airborne pathogens or immunocompromised clients, not for enteric infections like C. difficile. This intervention would not reduce transmission risk in this case.
D. Instruct the parents to avoid bringing fresh flowers into the room: This precaution is typically for neutropenic or immunocompromised clients to reduce exposure to potential fungal spores. C. difficile precautions focus on containment of fecal-oral transmission routes, not environmental fungal sources.
Correct Answer is A
Explanation
Rationale:
A. A client who gave birth 6 hr ago and just received a dose of methylergonovine: Methylergonovine is used to control postpartum hemorrhage but can cause severe hypertension or other adverse effects. Close monitoring immediately after administration is critical to detect complications early.
B. A client who gave birth 24 hr ago and has had a urinary output of 2800 mL: Increased urinary output postpartum is common due to diuresis as the body eliminates excess fluid; this is not an urgent concern if the client is otherwise stable.
C. A client who is 3 days postpartum and reports bilateral breast fullness: Breast engorgement is common around this time and is expected. It can be managed with supportive measures and is not an immediate priority.
D. A client who gave birth 8 hr ago and has moderate perineal edema: Perineal edema is expected postpartum and usually resolves with routine care. Unless associated with severe pain or signs of infection, it does not require immediate attention.
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