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

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

a. Close the documentation program on the computer:

This action is appropriate as it immediately stops unauthorized access to the client's medical information and prevents further viewing of protected health information (PHI).

b. Find out which staff member left the documentation program on the screen:

While it's important to identify any staff member who may have left the documentation program open, addressing this issue should not be the first priority. The immediate concern is stopping the unauthorized access to the client's information and ensuring that the visitor is aware of the confidentiality breach.

c. Tell the charge nurse that the visitor viewed a client’s protected health information:

Notifying the charge nurse about the incident is important, but it should not be the first action taken. The priority is to address the immediate breach of confidentiality and prevent further unauthorized access to the client's information.

d. Inform the visitor that client records are confidential:

This action may be appropriate after addressing the immediate breach of confidentiality. However, it should not be the first action taken as it does not immediately stop the unauthorized access to the client's information.

A. Places food on the stronger side of the client’s mouth B. Positions the client at a 30 degree angle prior to eating C. Instructs the client to hyperextend their neck when swallowing D. Has the client sit upright for 20 min following meals

Correct Answer is A

Explanation

A. Places food on the stronger side of the client’s mouth: Placing food on the stronger side of the mouth helps the client chew and swallow more effectively and safely. This compensates for weakness on one side, reducing the risk of choking and aspiration.

B. Positions the client at a 30-degree angle prior to eating:A 30-degree angle is insufficient to reduce the risk of aspiration in clients with dysphagia. The client should be positioned in an upright sitting position (90 degrees) to facilitate safer swallowing and reduce the risk of choking or aspirating food.

C. Instructs the client to hyperextend their neck when swallowing:Hyperextending the neck (tilting the head back) can actually increase the risk of aspiration by opening the airway, making it easier for food or liquids to enter the lungs. The client should be encouraged to tuck the chin slightly when swallowing to protect the airway.

D. Has the client sit upright for 20 minutes following meals: While sitting upright after meals is beneficial for preventing reflux and aspiration, 20 minutes is not sufficient. The client should remain upright for at least 30 minutes after meals to further reduce the risk of aspiration.

View Question and Answer

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

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse enters the hallway and discovers a visitor looking at a client’s medical information on a computer. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A charge nurse is observing a licensed practical nurse assist a client who has dysphagia while eating. Which of the following actions by the LPN should the charge nurse identify as providing safe care?

Correct Answer is A

Explanation

A nurse is preparing to complete an incident report regarding a medication error. Which of the following actions should the nurse plan to take? SATA

A home health nurse is assessing an older adult client’s home after providing teaching about home safety. Which of the following actions by the client indicates an understanding of the teaching?

A nurse is conducting a disaster preparedness drill with a group of nurses who are orienting to the facility. Which of the following triage tag colors should the nurse instruct the group to apply to a client who has full thickness burns on 72% of his body?

A nurse is developing a discharge plan for a client who is postoperative and will require a wheelchair in the home. The nurse should place a referral to which of the following resources to assist the client with this need?

To resolve a conflict between staff members regarding potential changes in policy, a nurse manager decides to implement the changes she prefers regardless of the feelings of those who oppose those changes. Which of the following conflict resolution strategies is the nurse manager using?

A nurse is assisting with the orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and has difficulty completing care for his assigned clients. Which of the following interventions is appropriate?

A nurse is caring for a client who has cancer the client’s adult child asks the nurse for information about the client’s treatment plan. Which of the following responses should the nurse make?

A nurse on a medical-surgical unit is caring for a client who asks about advance directives and states that he wants to appoint a health care proxy. Which of the following responses should the nurse make?