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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Adolescents are at a stage of development where body image and appearance are of significant importance. Discussing how the procedure might affect the client's appearance allows the nurse to address the adolescent's concerns and fears related to changes in their body. This can help alleviate anxiety and promote a sense of control over the situation, fostering a more positive psychological response to the surgery.
Choice B rationale:
Avoiding involving the client in decisions regarding treatment (Choice B) would not be appropriate for an adolescent. Adolescents are at a stage where they are developing autonomy and decision-making skills. Excluding them from decisions about their treatment could lead to feelings of powerlessness and hinder their sense of control.
Choice C rationale:
Emphasizing that the procedure is not a punishment (Choice C) might be suitable for younger children who might associate medical procedures with punishment. However, adolescents typically do not perceive medical procedures as punishments, so this explanation may not address their specific concerns.
Choice D rationale:
Keeping equipment out of the client's sight (Choice D) might be more relevant for younger children who might be frightened by medical equipment. Adolescents are generally better able to comprehend and cope with the presence of medical equipment. Open communication about the procedure and addressing their concerns directly would be more beneficial.
Correct Answer is B
Explanation
Choice A rationale:
A 15-year-old client who requests testing for a sexually transmitted infection (STI) is seeking healthcare related to sexual health, which is often considered confidential. In many jurisdictions, minors of a certain age (often 12 or older) have the legal right to consent to STI testing and treatment without parental consent. While education on sexual health and responsible decision-making is important, in this case, the nurse may not need to involve the parent if the legal requirements are met.
Choice B rationale:
This is the correct answer. Minors generally require parental consent for medical procedures, including biopsies. A biopsy involves a medical intervention that can carry risks, and it is important to have informed parental consent for procedures on underage clients.
Choice C rationale:
A 16-year-old client who requires prenatal care for pregnancy is not applicable in this scenario. Prenatal care is focused on managing the health and well-being of a pregnant individual and their developing fetus. The question does not provide information that suggests this situation.
Choice D rationale:
A 13-year-old client who requests contraception advice may have the right to access contraception services without parental consent, depending on local laws and regulations. Many places allow minors to access contraception services confidentially, recognizing the importance of sexual health and preventing unintended pregnancies. However, it's always important for healthcare providers to assess each situation and the applicable legal framework to determine whether parental involvement is required.
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