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
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Correct Answer is C
Explanation
Choice A reason: Naltrexone is primarily used to manage alcohol or opioid dependence and is not typically prescribed for smoking cessation. It works by blocking the euphoric effects of these substances, which is not directly applicable to nicotine addiction.
Choice B reason: Disulfiram is used as a deterrent agent in the treatment of alcoholism. It causes unpleasant effects when even small amounts of alcohol are consumed, thus it is not suitable for smoking cessation.
Choice C reason: Varenicline is a medication specifically designed to aid in smoking cessation. It works by binding to nicotine receptors in the brain, reducing cravings and the pleasurable effects of smoking. This makes it easier for individuals to quit smoking.
Choice D reason: Donepezil is a medication used to treat cognitive symptoms of Alzheimer's disease. It is not indicated for smoking cessation and does not have an effect on nicotine addiction.
Correct Answer is C
Explanation
Choice A reason: This response is not therapeutic as it provides false assurance and may not be accurate. The return of the child depends on many factors beyond just attending counseling.
Choice B reason: While sedatives may be used to manage acute distress, this response does not address the client's expressed feelings of hopelessness and the risk of self-harm.
Choice C reason: This response directly addresses the client's statement about not wanting to live, which could indicate suicidal ideation. It is important to assess for the risk of self-harm or suicide.
Choice D reason: This response may be helpful in a long-term plan but does not address the immediate risk of harm to the client. It is also not guaranteed that a family member can obtain custody.
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