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: Eating 2 hours before an IVP is incorrect; fasting is required 4-8 hours prior to ensure clear imaging. Scientifically, food can obscure contrast in the urinary tract, reducing diagnostic accuracy, showing misunderstanding of prep needs.

Choice B reason: Limiting fluids post-IVP is wrong; hydration flushes dye, preventing kidney strain. Scientifically, adequate fluid intake post-contrast is standard to reduce nephrotoxicity risk, indicating the client misgrasps aftercare critical to renal safety.

Choice C reason: Not needing consent is false; IVP involves contrast risks (e.g., allergy), requiring informed consent. Scientifically, legal and medical standards mandate consent for invasive imaging, reflecting a lack of understanding about procedural protocols.

Choice D reason: A warming sensation from dye injection is accurate, as contrast dilates vessels briefly. Scientifically, this common reaction shows the client understands the procedure’s sensory effects, aligning with expected physiological responses per IVP education.

A. Epigastric pain B. Seizure activity C. Sudden loss of vision in one eye D. Pain radiating down the left arm

Correct Answer is C

Explanation

Choice A reason: Epigastric pain suggests GI issues, not TIAs. In hypertension, TIAs affect cerebral vessels, causing neurological deficits, not abdominal symptoms like this.

Choice B reason: Seizures stem from cortical irritation, not typical TIA vascular occlusion. Hypertension-related TIAs produce transient deficits, not convulsive activity usually.

Choice C reason: Sudden monocular vision loss (amaurosis fugax) is a classic TIA sign in hypertension. It reflects temporary retinal artery occlusion, resolving quickly.

Choice D reason: Left arm pain mimics cardiac issues, not TIAs. Hypertension TIAs target brain circulation, causing focal deficits, not referred pain patterns.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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