A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply.)
Identify the client's stressors.
Talk to the client using short, simple sentences.
Speak to the client in a loud voice.
Request that security guards restrain the client.
Stand directly in front of the client.
Correct Answer : A,B
Choice A reason: Identifying the client's stressors is a crucial step in managing agitation. Understanding what triggers the client's distress can help the nurse to address the underlying issues and de-escalate the situation.
Choice B reason: Using short, simple sentences can help to communicate effectively with an agitated client. It ensures that the client can process the information without being overwhelmed, which is important for calming the situation.
Choice C reason: Speaking to the client in a loud voice is not recommended as it may escalate the situation. It's important to maintain a calm and soothing tone to avoid further agitation.
Choice D reason: Requesting that security guards restrain the client should be a last resort, only if the client poses an immediate threat to themselves or others. Less restrictive measures should be attempted first.
Choice E reason: Standing directly in front of an agitated client can be perceived as confrontational. It's better to maintain a non-threatening stance and ensure there is enough space to allow the client to feel safe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B. Obtain a prescription for seclusion within 30 minutes. This ensures the seclusion is legally and ethically justified.
Choice A reason:
Keeping the client in seclusion for no longer than 6 hours is incorrect because the maximum duration for seclusion without reassessment is typically 4 hours for adults.
Choice B reason:
Obtaining a prescription for seclusion within 30 minutes is correct as it ensures the seclusion is legally and ethically justified.
Choice C reason:
Monitoring the client's vital signs every 4 hours is incorrect because vital signs should be monitored more frequently, usually every 15 minutes to 1 hour.
Choice D reason:
Documenting the client's behavior every 60 minutes is incorrect because documentation should occur more frequently, typically every 15 minutes.
Correct Answer is A
Explanation
Choice A reason: This response is appropriate because it respects the client's autonomy and comfort level. It is essential to acknowledge the client's feelings and preferences, especially when dealing with mental health issues like panic disorder. Massage therapy, while beneficial for some, may not be suitable for everyone, particularly if the idea of being touched exacerbates the client's anxiety. By offering to communicate the client's concerns to the provider, the nurse acts as an advocate for the client's well-being and ensures that the treatment plan is tailored to the client's specific needs and comfort.
Choice B reason: While this option might seem like a compromise, it does not address the client's fundamental discomfort with being touched. Wearing gloves may not alleviate the distress associated with physical contact for someone with panic disorder. It is crucial to consider the client's psychological state and the potential for gloves to serve as a reminder of the unwanted touch, possibly leading to increased anxiety rather than relief.
Choice C reason: Asking the client to explain their discomfort could be seen as dismissive of the client's stated boundaries and may put them in an uncomfortable position to justify their feelings. It is important for healthcare professionals to create a safe and supportive environment where clients do not feel pressured to defend their preferences or feelings, especially when they are already experiencing distress.
Choice D reason: This choice minimizes the client's concerns and could be perceived as invalidating their feelings. Telling a client not to worry about their anxiety, particularly in the context of a panic disorder, overlooks the complexity of the condition. Anxiety disorders can significantly impact a person's life, and reassurances like this may not be helpful and could potentially worsen the client's anxiety.
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