. A nurse is caring for a client who is becoming agitated. While attempting to deescalate, which of the following actions should the nurse take first?

Select a quiet location to talk to the client while remaining visible to staff members.

Give the client several clear options.

Observe the client and the situation.

Respect the client's personal space.

Answer and Explanation

The Correct Answer is C

A. Selecting a quiet location is important, but first, it is essential to assess the client's current state and the surrounding environment.

B. Providing options can help empower the client, but it is best to first observe the client to gauge their level of agitation and determine the appropriate response.

C. Observing the client and the situation allows the nurse to understand the severity of the agitation and the context, which is critical for making informed decisions about the next steps.

D. Respecting personal space is important, but it should follow an assessment of the situation to ensure safety for both the client and staff.

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Correct Answer is B

Explanation

A. While offering choices can promote autonomy, allowing clients to choose their own mealtimes may lead to avoidance of meals and is not a structured approach needed for clients with anorexia nervosa.

B. Supervision during and after eating is critical in managing clients with anorexia nervosa to ensure they consume the necessary nutrients and to monitor for any harmful behaviors, such as purging.

C. Although providing choices can support autonomy, it may not be suitable for clients with anorexia nervosa, as they might choose low-calorie or unhealthy options.

D. Encouraging casual conversation about food can sometimes increase anxiety or lead to fixation on eating behaviors, making it an inappropriate strategy for this population.

A. Muscle Rigidity B. Constipation C. Nausea D. Wheezing

Correct Answer is C

Explanation

A. Muscle rigidity is not a typical manifestation of digoxin toxicity; it is more commonly associated with other conditions or medications.

B. Constipation can occur but is not a primary sign of digoxin toxicity.

C. Nausea is a common early sign of digoxin toxicity and should be included in the teaching. Other symptoms may include vomiting, visual disturbances, and confusion.

D. Wheezing is not associated with digoxin toxicity; it may suggest respiratory issues or an allergic reaction.

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. A nurse is caring for a client who is becoming agitated. While attempting to deescalate, which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute mental health facility is planning care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the client's plan of care?

Correct Answer is B

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A nurse is teaching a client who has a new prescription for digoxin about manifestations of toxicity. Which of the following findings should the nurse include in the teaching?

Correct Answer is C

Explanation

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