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.

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Correct Answer is C

Explanation

a. Help the AP assist the client with the transfer.

While it is important to instruct the AP to seek assistance when unsure, this does not immediately address the safety of the client during the current incorrect transfer.

b. Demonstrate the proper client transfer technique to the AP.

Demonstrating the proper technique is an important step, but it should come after ensuring the immediate safety of the client. This can be done once the client is safely transferred.

c. Instruct the AP to request assistance when unsure about a task.

Correct. The nurse's first priority should be the safety of the client. By immediately assisting the AP with the transfer, the nurse ensures the client's safety and prevents potential injury.

d. Refer the AP to the facility procedure manual.

Referring the AP to the procedure manual is important for future reference, but it does not address the immediate risk to the client. This action can be taken after ensuring the client's safety and demonstrating the correct technique.

A. Review the chart for nonrestraint alternatives for agitation B. Inform the unit manager of the incident C. Speak with the AP about the incident D. Remove the restraints from the client’s wrists

Correct Answer is D

Explanation

a. Review the chart for nonrestraint alternatives for agitation:

This action involves assessing the client's history, current condition, and any documented alternatives to restraints for managing agitation. While exploring nonrestraint interventions is important, addressing the immediate issue of inappropriate restraint use should take precedence.

b. Inform the unit manager:

Notifying the unit manager about the incident is important for escalating the situation and involving higher-level management in addressing the inappropriate use of restraints. However, before escalating, the immediate needs of the client should be addressed.

c. Speak with the AP about the incident:

Engaging in a conversation with the assistive personnel (AP) who applied the restraints allows for clarification of the situation, identification of any misunderstandings or training needs regarding restraint use, and immediate removal of the restraints if necessary. However, ensuring the client's safety should be the first priority.

d. Remove the restraints from the client’s wrist:

In situations where restraints are applied without a prescription or appropriate authorization, it is crucial to remove the restraints promptly to prevent potential harm to the client. However, it is essential to address the root cause of the inappropriate use of restraints and ensure that the client receives appropriate care and monitoring following restraint removal.

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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 manager observes an assistive personnel incorrectly transferring a client to the bedside commode. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A charge nurse making rounds observes that an assistive personnel has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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