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.

Answer and Explanation

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.

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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.

A. A child who was conceived by in vitro fertilization B. A toddler who has atopic dermatitis C. An only child D. A school-age child who has cerebral palsy

Correct Answer is D

Explanation

Rationale:

A. A child who was conceived by in vitro fertilization: Children conceived through IVF are typically highly desired and planned for, and families may invest significant emotional and financial resources into their care. This background generally reduces rather than increases the risk of maltreatment.

B. A toddler who has atopic dermatitis: Although chronic conditions can be stressful for caregivers, atopic dermatitis is relatively common and manageable. It does not significantly increase the risk of child abuse or neglect compared to more severe or demanding conditions.

C. An only child: Being an only child does not inherently increase the risk for maltreatment. Risk factors for abuse are more closely associated with caregiver stress, socioeconomic status, substance use, and the presence of physical or cognitive impairments in the child.

D. A school-age child who has cerebral palsy: Children with disabilities like cerebral palsy are at higher risk for maltreatment due to the physical, emotional, and financial stress their care may place on caregivers. These children often require more supervision and support, which can lead to frustration or neglect in high-risk environments.

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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?

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