A nurse is caring for a client in the emergency department (ED).
Which of the following interventions should the nurse implement?
Stay with the client.
Place the client in a room close to the nurses' station.
Offer the client a caffeinated beverage.
Weigh the client daily.
Offer the client finger foods.
Correct Answer : A
It is essential for the nurse to stay with the client in this situation. The client's presentation indicates manic behavior, which can be associated with bipolar disorder. Manic episodes can lead to increased energy levels, decreased need for sleep, agitation, and impulsivity. The client's refusal to sit down, pacing, and becoming agitated when asked questions all indicate potential risk to themselves or others. Staying with the client ensures their safety and the safety of others in the environment. The nurse can provide verbal support, prevent potential harm, and de-escalate the situation if needed.
Placing the client in a room close to the nurses' station might be helpful for monitoring and quick assistance, but it doesn't directly address the client's immediate agitation and need for supervision. The priority in this scenario is to ensure the client's safety, which can be achieved by staying with them.
Offering the client a caffeinated beverage is not appropriate in this situation. Caffeine can exacerbate agitation and restlessness, potentially worsening the client's symptoms. It's important to provide a calm and supportive environment instead.
Weighing the client daily is not relevant to the current situation. The client's agitation and need for supervision take precedence over routine assessments like daily weight measurement.
Offering the client finger foods is also not appropriate in this situation. The client's behavior and presentation suggest a manic episode, and their agitation indicates that they are not in a state to engage in eating. Ensuring safety and providing emotional support are the immediate priorities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
"I should start by feeding my baby 3 tablespoons of solid food." At 6 months of age, infants are typically just beginning to transition to solid foods. Starting with 3 tablespoons of solid food might be overwhelming and inappropriate for the infant's digestive system. Introducing small amounts and gradually increasing the volume allows the infant to adapt to the new textures and flavors.
Choice B rationale:
"I should limit my baby to 8 ounces of juice per day." Juice consumption should be limited for infants. Juice offers little nutritional value and can contribute to excessive calorie intake, leading to potential weight gain and tooth decay. At 6 months, the primary source of nutrition should still be breast milk or formula, and the introduction of solid foods is meant to complement, not replace these sources.
Choice C rationale:
"I should introduce a new solid food to my baby every five to seven days." This statement indicates an understanding of the recommended approach for introducing solid foods to an infant. Introducing a new food every five to seven days allows the parent to monitor for any potential allergic reactions or sensitivities. This gradual approach helps identify specific foods that the infant may not tolerate well.
Choice D rationale:
"I should sweeten my baby's food with a teaspoon of honey." This statement is incorrect and potentially dangerous. Honey should not be given to infants under 12 months of age due to the risk of infant botulism, a serious and potentially fatal illness. Honey can contain spores of Clostridium botulinum bacteria, which can multiply and produce toxins in an infant's immature digestive system. It's important to avoid honey until the child is older to ensure their safety.
Correct Answer is D
Explanation
The correct answer is choice D, wooden building blocks.
Choice A rationale:
Colored paper and safety scissors are not appropriate for an 18-month-old child due to safety concerns. At this age, children are still developing fine motor skills and coordination, and the use of scissors, even safety ones, poses a risk of injury.
Choice B rationale:
Stringing beads is not suitable for an 18-month-old child as it requires more advanced fine motor skills and could pose a choking hazard. Children at this age are still prone to exploring objects by putting them in their mouths.
Choice C rationale:
Alphabet flash cards are not the best choice for an 18-month-old child with pneumonia. While flash cards can be educational, they are more suited for older children who are beginning to learn letters and words. At 18 months, play should focus on sensory and motor skill development rather than academic learning.
Choice D rationale:
Wooden building blocks are the most appropriate choice for an 18-month-old child. They encourage play that is developmentally supportive, promoting fine motor skills and creativity. Blocks can be easily handled by small hands, and there is no risk of injury or choking. Additionally, building and knocking down block towers can provide a sense of accomplishment and enjoyment for the child.
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