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 A

Explanation

Choice A reason: Hearing loss is a known gentamicin ototoxicity effect, damaging cochlear hair cells irreversibly. Scientifically, this aminoglycoside targets the inner ear, causing tinnitus or deafness, a critical adverse reaction to monitor in pyelonephritis treatment per pharmacology evidence.

Choice B reason: Slurred speech suggests neurological issues (e.g., stroke), not gentamicin effects. Scientifically, this drug affects kidneys and ears, not speech centers, making this unrelated to its toxicity profile, which focuses on auditory and renal damage.

Choice C reason: Constipation isn’t linked to gentamicin; it’s more typical of opioids or immobility. Scientifically, this antibiotic’s side effects center on nephrotoxicity and ototoxicity, not gastrointestinal motility, rendering this an unlikely adverse reaction in this context.

Choice D reason: Hypotension may occur with rapid IV gentamicin, but it’s less common than ototoxicity. Scientifically, hearing loss is a hallmark toxicity, outweighing transient blood pressure drops, which are manageable and less specific to this drug’s adverse profile.

A. Sleep apnea B. Paresthesias C. Disorientation D. Tonic-clonic seizures

Correct Answer is C

Explanation

Choice A reason: Sleep apnea isn’t an ECT effect; it’s a chronic breathing disorder. ECT may cause transient respiratory changes intra-procedure, not post. Scientifically, this lacks relevance, as 15-minute post-ECT findings focus on neurological recovery, not sleep-related respiratory patterns.

Choice B reason: Paresthesias (tingling) aren’t typical post-ECT; they suggest nerve issues unrelated to brain stimulation. ECT affects cognition, not peripheral sensation. Scientifically, this doesn’t align with expected acute neurological outcomes, which prioritize confusion over sensory disturbances.

Choice C reason: Disorientation is common 15 minutes post-ECT due to generalized seizure effects on brain function, impairing memory and awareness. Scientifically, this reflects transient postictal confusion, a standard response as neural activity normalizes, aligning with ECT’s cognitive impact.

Choice D reason: Tonic-clonic seizures occur during ECT, not after; post-procedure seizures suggest complications. At 15 minutes, recovery, not new seizures, is expected. Scientifically, this contradicts typical post-ECT progression, where brain stabilizes rather than re-enters convulsive states.

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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 A

Explanation

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Correct Answer is C

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