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. Notify the unit manager: Informing the unit manager is necessary for institutional follow-up and quality assurance. However, it is not the immediate concern. Client safety and clinical status must be assessed first to determine if harm has occurred due to the error.
B. Collect data on the client: Assessing the client is the priority to determine if the excessive fluid has caused complications such as fluid overload, pulmonary edema, or changes in vital signs. Early identification of adverse effects is essential to guide further intervention.
C. Notify the provider: The provider should be informed after assessing the client so that appropriate medical interventions or monitoring can be initiated. Immediate data collection ensures the nurse can give accurate information about the client’s status.
D. Complete an incident report: Documentation of the error is an important step for institutional learning and accountability. However, it is not time-sensitive in the way client safety and assessment are and should follow after urgent clinical actions are taken.
Correct Answer is B
Explanation
Rationale:
A. Encourage the client to increase fluid intake: Clients receiving continuous peritoneal dialysis may need to restrict fluids to prevent volume overload, depending on residual kidney function and dialysis efficiency. Encouraging increased intake without provider orders can be harmful.
B. Obtain the client's weight: Daily weight is a critical indicator of fluid balance and dialysis effectiveness. Monitoring weight helps determine if the dialysis is removing the appropriate amount of fluid and supports adjustments to the treatment plan.
C. Palpate the access site for a thrill: A thrill is a vibration felt over an arteriovenous fistula, which is used in hemodialysis, not peritoneal dialysis. Peritoneal dialysis uses a soft catheter in the abdomen and does not produce a thrill.
D. Auscultate the access site for a bruit: A bruit, a whooshing sound heard over a vascular access, is associated with AV fistulas used in hemodialysis. It is not relevant for peritoneal dialysis, which uses a catheter and does not involve high-pressure blood flow.
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