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:
Perfectionistic behavior is not typically considered a behavioral finding indicative of sexual abuse in a school-age child. Perfectionism may be related to personality traits, family dynamics, or individual tendencies, but it is not a specific behavioral marker for sexual abuse.
Choice B rationale:
Manipulative behavior is not a specific indicator of sexual abuse in a school-age child. Children can display manipulative behavior for various reasons, including seeking attention or attempting to control situations. While behavioral changes can occur in response to trauma, manipulative behavior alone does not necessarily point to sexual abuse.
Choice C rationale:
Withdrawn behavior is a possible indication of sexual abuse in a school-age child. Sexual abuse can cause emotional and psychological distress in children, leading them to withdraw from social interactions. They might become isolated, exhibit changes in their usual behavior, and show decreased interest in activities they previously enjoyed.
Choice D rationale:
Destructive behavior is not a prominent behavioral finding associated specifically with sexual abuse in a school-age child. Destructive behaviors can arise from a range of factors, including emotional difficulties, behavioral disorders, or reactions to stressors. While trauma like sexual abuse can influence behavior, it's not a defining characteristic of sexual abuse in isolation.
Correct Answer is D
Explanation
Choice A rationale:
Tinnitus is the perception of noise or ringing in the ears. It can be caused by various factors, including exposure to loud noises, ear infections, and certain medications. However, tinnitus is not a commonly reported adverse effect of albuterol, which is a bronchodilator used to treat conditions like asthma and other respiratory disorders.
Choice B rationale:
Constipation is not a commonly reported adverse effect of albuterol. Albuterol primarily acts on the smooth muscles of the airways to relax and dilate them, improving airflow. Constipation is more likely related to issues with the gastrointestinal system or certain medications, but it is not a direct consequence of albuterol use.
Choice C rationale:
Hypoglycemia, or low blood sugar, is not a known adverse effect of albuterol. Albuterol primarily affects the respiratory system and does not typically impact blood glucose levels. Hypoglycemia is more commonly associated with diabetes medications like insulin or certain oral hypoglycemic agents.
Choice D rationale:
Headache is a potential adverse effect of albuterol. While not everyone will experience a headache when taking albuterol, it can occur as a side effect in some individuals. Albuterol can stimulate the sympathetic nervous system, leading to effects such as increased heart rate and potential vasodilation, which could contribute to the development of a headache in some cases. It's important for the parents of a child taking albuterol to be aware of potential side effects and report them to the healthcare provider if they occur.
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