A nurse is caring for a client who is visibly agitated and talking loudly in a group therapy session. Which of the following actions should the nurse take first?

Place the client in seclusion.

Assist the client with understanding their needs.

Ask the client to identify what made them upset.

Administer lorazepam IM.

Answer and Explanation

The Correct Answer is C

Choice A reason: Seclusion is a last resort, not first, per de-escalation principles. It risks escalating agitation or trauma without addressing the cause. Scientifically, verbal intervention precedes restraint, as identifying triggers can calm the client, aligning with evidence-based psychiatric care prioritizing least restrictive measures.

Choice B reason: Assisting with needs is vague and secondary to identifying the agitation’s source. Without understanding the trigger, this lacks focus. Scientifically, pinpointing the upset first guides effective support, making this a follow-up, not initial, step in managing acute behavioral distress.

Choice C reason: Asking what upset the client de-escalates by engaging them, identifying triggers for targeted intervention. This aligns with scientific psychiatric practice, reducing agitation through communication before medication or seclusion, addressing the root cause effectively as the first step in evidence-based care.

Choice D reason: Administering lorazepam IM is premature without de-escalation attempts. It risks over-sedation or side effects, bypassing verbal strategies. Scientifically, medication follows failed non-pharmacological efforts per guidelines, making this a later option, not the first, in managing agitation safely and effectively.

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Correct Answer is D

Explanation

Choice A reason: Sims’ position is for rectal exams, not central catheter insertion. Trendelenburg or supine is used, so this is incorrect for TPN prep.

Choice B reason: Verifying TPN amount is ongoing care, not insertion prep. Initial placement confirmation via x-ray takes precedence over infusion monitoring here.

Choice C reason: Clean technique risks infection in central lines; sterile is required. This compromises TPN safety, making it an incorrect preparatory step.

Choice D reason: Chest x-ray confirms catheter tip placement in the vena cava for TPN. It’s a critical prep step to ensure safe administration begins.

A. Massage the affected extremity every 4 hr. B. Initiate bed rest. C. Apply an ice pack to the affected extremity for 20 min every 2 hr. D. Administer aspirin for pain.

Correct Answer is B

Explanation

Choice A reason: Massaging a DVT risks dislodging the clot, causing embolism. In postpartum with anticoagulants, this is contraindicated to prevent lethal complications.

Choice B reason: Bed rest minimizes clot movement in DVT, aiding anticoagulation postpartum. It reduces embolism risk, a critical safety measure in this scenario.

Choice C reason: Ice may reduce swelling, but it’s not standard for DVT with anticoagulants. Elevation and rest are prioritized over cold therapy here.

Choice D reason: Aspirin isn’t used with anticoagulants like heparin; it increases bleeding risk. Postpartum DVT needs specific pain management, not this drug.

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A nurse is caring for a client who is visibly agitated and talking loudly in a group therapy session. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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