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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.5"]
Explanation
To calculate the amount of ziprasidone 10 mg IM from the available concentration of 20 mg/mL, you can use the formula:
Amount (mL) = Desired Dose (mg) / Concentration (mg/mL)
Amount (mL) = 10 mg / 20 mg/mL
Amount (Ml) = 0.5 mL
Therefore, the nurse should administer 0.5 mL of ziprasidone per dose.
Correct Answer is D
Explanation
A. "We can call your family in time for them to get here."
While involving the family is important, this response assumes that the client's concern is solely about family being present. The client's statement might have deeper emotional layers, such as fear or regret, that should be addressed.
B. "Tell your family of your concern so that they can be here."
This response puts the responsibility on the client to communicate their concerns to the family. The nurse's role is to provide support and facilitate communication, rather than placing the burden on the client.
C. "I will make sure a staff member is in your room at all times."
While ensuring the client is not alone is important, this response doesn't address the client's emotional concerns or open a dialogue about their feelings. Simply having a staff member present might not address the underlying fear or anxiety the client is experiencing.
D. "I wonder if you are fearful of dying alone."
Explanation: The nurse's response empathizes with the client's feelings and invites a conversation about their emotions. It acknowledges the client's concerns and opens the door for a more in-depth discussion about their fears and feelings regarding dying alone. This approach is patient-centered and encourages the client to express their emotions.
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