A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?

Remain with the client.

Give to client a PRN sleeping medication,

Encourage the client to go back to bed.

Explore alternatives to pacing the floor with the client.

Answer and Explanation

The Correct Answer is A

Remaining with the client provides support and ensures their safety. The client's behavior indicates distress, and having a nurse nearby can help the client feel more comfortable and secure.

B. Give the client a PRN sleeping medication:

Explanation: Administering a sleeping medication should not be the first response, especially if the client is agitated. It's important to address the underlying cause of the agitation and consider other interventions before resorting to medication.

C. Encourage the client to go back to bed:

Explanation: Encouraging the client to go back to bed might not be effective if they are experiencing significant distress or anxiety. It's better to address their emotional state first before suggesting any changes in activity.

D. Explore alternatives to pacing the floor with the client:

Explanation: This is a reasonable course of action. Exploring alternatives to the client's current behavior can help address their distress and find ways to manage their emotions more effectively.

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Correct Answer is C

Explanation

A. The client will implement alternative strategies for managing anxiety.

While addressing anxiety is important for the overall well-being of the client, it may not be the highest priority in this context. The immediate physical safety of the client during alcohol withdrawal takes precedence over addressing anxiety.

B. The client will acknowledge alcohol dependence and need for treatment.

Recognizing alcohol dependence and the need for treatment is an important step, but it may not be the highest priority. It is more focused on the client's acceptance and understanding of their situation rather than addressing immediate health risks.

C. The client's withdrawal from alcohol will be managed without complications.

This is the correct answer. Managing alcohol withdrawal without complications is the highest priority goal in this scenario. Alcohol withdrawal can lead to severe physical symptoms, including seizures and delirium tremens, which can be life-threatening. Ensuring the safe and medically supervised management of withdrawal is crucial for the client's immediate well-being.

D. The client will rebuild damaged interpersonal relationships.

While repairing damaged relationships is important for the client's overall rehabilitation, it's not the highest priority in this context. Physical health and safety take precedence over addressing interpersonal issues.

A. Discuss self-defense techniques with the client. B. Give the client a bed bath prior to physical examination. C. Inform the client photographs of injuries are required for a police report. D. Ask the client to describe the situation.

Correct Answer is D

Explanation

A. Discuss self-defense techniques with the client: Incorrect

While self-defense techniques can be useful information, discussing them immediately after a traumatic event like sexual assault may not be appropriate. The client's immediate needs for emotional support, medical evaluation, and safety are more pressing.

B. Give the client a bed bath prior to physical examination: Incorrect

In cases of sexual assault, preserving evidence is important for legal purposes and for the client's well-being. Providing a bed bath could potentially compromise evidence and hinder a thorough examination by healthcare professionals.

C. Inform the client photographs of injuries are required for a police report: Correct

Preserving evidence is crucial in cases of sexual assault, especially if the client intends to involve law enforcement. Informing the client about the importance of photographs for a police report is appropriate and can contribute to a potential legal investigation.

D. Ask the client to describe the situation: Correct

It's important to encourage the client to share their experience, but it should be done in a sensitive and supportive manner. Gathering information about the situation can help the healthcare team understand the scope of the assault, provide appropriate medical care, and offer necessary emotional support.

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A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a rehabilitation center is planning care for a newly admitted client who has a history of alcohol use disorder. Which of the following client goals is the highest priority?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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