A nurse is caring for a client who wanders through the halls yelling obscenities at staff, other clients, and visitors. Which of the following action should the nurse take?
Administer a sedative to the client
Contact a family member to come and sit with the client
Place the client in a wheelchair with a lap tray
Keep the client in her room with the door closed
The Correct Answer is B
a. Administer a sedative to the client:
Administering a sedative may temporarily calm the client, but it should not be the first-line intervention, especially without a physician's order. Sedatives carry risks and should only be used when other interventions have been considered and deemed ineffective or when the client's behavior poses an immediate danger to themselves or others.
b. Contact a family member to come and sit with the client: could indeed be a valid first step. If a family member is available and able to assist, they could potentially calm the client without the need for isolation and reducing disruptive behavior. However, if this is not feasible, then ensuring the client’s safety through temporary isolation with frequent checks might be necessary.
c. Place the client in a wheelchair with a lap tray:
Placing the client in a wheelchair with a lap tray may restrict their movement and potentially exacerbate agitation or aggression. It does not address the underlying reasons for the behavior and may not be an appropriate intervention for managing wandering behavior.
d. Keep the client in her room with the door closed:
Isolating a client in their room could be considered a form of restraint or isolation and should be used with caution. This should be used only after other less restrictive measures have been tried and deemed ineffective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. "You must choose a member of your family to serve as your health care proxy":
This response is not accurate. While family members are often chosen as healthcare proxies, the client is not required to select a family member. The most important consideration is choosing someone who understands the client's healthcare wishes and is willing and able to advocate for them. The nurse should emphasize the importance of selecting a trusted individual, whether they are a family member or not.
b. "A health care proxy can make decisions for you when you are unable to do so":
This response is accurate. A healthcare proxy is a legal document that allows an individual to appoint someone else to make healthcare decisions on their behalf if they become unable to do so due to illness or incapacity. The nurse should explain the role of a healthcare proxy in advocating for the client's wishes and ensuring that their healthcare preferences are honored.
c. "You should appoint a health care proxy before undergoing an invasive procedure":
While it is advisable for clients to have advance directives, including a healthcare proxy, in place before undergoing any medical procedure, this response does not fully address the client's question. The timing of appointing a healthcare proxy should not be limited to specific medical procedures but should be based on the client's readiness to make such decisions and their recognition of the importance of having a designated advocate for their healthcare needs.
d. "It is necessary for an attorney to approve your health care proxy":
This response is not accurate. While it may be helpful to seek legal advice when creating advance directives, including a healthcare proxy, it is not a requirement for an attorney to approve the document. The client can typically complete a healthcare proxy form themselves, following the legal requirements of their jurisdiction. However, consulting with an attorney can provide additional guidance and ensure that the document is properly executed.
Correct Answer is D
Explanation
a. A client who reports night sweats and fever for the last week:
Night sweats and fever can be indicative of various underlying conditions, including infections. While these symptoms may require medical attention, they do not necessarily indicate an immediately life-threatening condition compared to other options.
b. A client who has compound fractures of the tibia and humerus:
Compound fractures involve broken bones that penetrate through the skin, leading to a risk of severe bleeding, infection, and other complications. This client's injuries are significant and require immediate attention to prevent further complications and provide pain management and stabilization.
c. A client who reports severe vomiting and diarrhea:
Severe vomiting and diarrhea can lead to dehydration, electrolyte imbalances, and other complications, especially if prolonged or accompanied by other symptoms such as fever. While this client requires prompt assessment and treatment, the urgency may not be as high as for other conditions.
d. A client who has soot markings around each naris following a house fire:
Soot markings around the nares (nostrils) suggest inhalation injury, which can lead to airway compromise, respiratory distress, and other serious complications. This client requires immediate assessment and intervention to ensure airway patency, oxygenation, and respiratory support.
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