A nurse is caring for a client who has become violent and is threatening self-harm following a crisis. After ensuring enough staff are available, which of the following actions should the nurse take first?

Administer a sedative medication.

Perform a debriefing with the staff.

Acknowledge the client's emotions.

Place the client in restraints.

Answer and Explanation

The Correct Answer is C

A reason: Administer a sedative medication. While administering a sedative may be necessary to calm the client, it is not the first step. The nurse should initially attempt to de-escalate the situation using non-pharmacological interventions.

B reason: Perform a debriefing with the staff. Debriefing with the staff is important after the situation is under control, but it is not the immediate priority. The focus should first be on addressing the client's behavior and emotions.

C reason: Acknowledge the client's emotions. Acknowledge the client's emotions to de-escalate the situation and help the client feel heard and understood. This can reduce the immediate risk of violence or self-harm.

D reason: Place the client in restraints. Restraints should be used as a last resort when other interventions have failed and there is an immediate risk of harm. The nurse should first try to calm the client through verbal and emotional support.

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Correct Answer is C

Explanation

A reason: "These clients can receive packages after they are privately inspected by security." While security measures might be in place for the safety of all clients, it does not address a fundamental right of involuntarily admitted clients.

B reason: "These clients cannot be considered for a research study." Involuntarily admitted clients can be considered for research studies, but participation must be voluntary, and informed consent is required.

C reason: "These clients can vote in local and federal elections." Clients who are involuntarily admitted retain their civil rights, including the right to vote in local and federal elections. This statement accurately reflects their rights.

D reason: "These clients cannot refuse their prescribed antipsychotic medications." Involuntarily admitted clients retain the right to refuse medication, except in specific situations where they are deemed a danger to themselves or others, and legal protocols are followed.

A. Polyphagia. B. Fever. C. Bradycardia. D. Oliguria.

Correct Answer is B

Explanation

A reason: Polyphagia. Polyphagia, or excessive eating, is not typically associated with cocaine use. Cocaine often suppresses appetite rather than increasing it.

B reason: Fever. Cocaine use can lead to hyperthermia or elevated body temperature due to increased metabolic activity and stimulation of the central nervous system.

C reason: Bradycardia. Bradycardia, or a slow heart rate, is not a typical response to cocaine use. Cocaine is a stimulant that usually causes tachycardia, or a rapid heart rate.

D reason: Oliguria. Oliguria, or reduced urine output, is not a typical finding associated with acute cocaine use. The drug's immediate effects are more related to cardiovascular and neurological systems.

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A nurse is caring for a client who has become violent and is threatening self-harm following a crisis. After ensuring enough staff are available, which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is B

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