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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A 90-degree angle is too upright; newborns need a 30-45-degree recline to protect airways. This shows misunderstanding of safe positioning.
Choice B reason: Rear-facing until age 2 supports neck and spine safety, per guidelines. This reflects correct understanding of car seat standards for newborns.
Choice C reason: Retainer clips belong at chest level, not belly, for harness safety. This indicates incorrect knowledge of car seat strap placement.
Choice D reason: Airbags endanger front-seat infants; rear seating is mandatory. Enabling them shows a dangerous misunderstanding of car seat safety protocols.
Correct Answer is D
Explanation
Choice A reason: Offering multiple choices overwhelms a delirious client, whose impaired cognition struggles with decisions. Scientifically, delirium reduces attention and processing, so simplifying options aids comfort, making this counterproductive to managing their acute confusional state effectively.
Choice B reason: Alternating caregivers disrupts continuity, worsening disorientation in delirium. Consistent faces aid recognition, reducing anxiety. Scientifically, familiarity stabilizes perception in acute confusion, making this detrimental to the client’s need for a predictable environment during recovery.
Choice C reason: Avoiding fears ignores emotional distress, potentially increasing agitation in delirium. Addressing concerns gently can calm. Scientifically, unaddressed anxiety exacerbates confusion, so this neglects a holistic approach needed for managing the client’s psychological state effectively.
Choice D reason: Reminding of day and time reorients the client, countering delirium’s disorientation. Frequent cues anchor perception, aiding recovery. Scientifically, this aligns with evidence-based care, as repeated orientation reduces confusion’s impact, supporting cognitive stabilization in acute delirium management.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.