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 A
Explanation
a. Decreased level of consciousness:
This finding is concerning and may indicate worsening neurological status, increased intracranial pressure, or impending herniation. A decreased level of consciousness requires immediate evaluation by the provider to assess for neurological deterioration and potential interventions to stabilize the client's condition.
b. Increased temperature:
While an increased temperature (fever) is commonly associated with meningitis due to the inflammatory response, it may not necessarily require immediate reporting unless it is extremely high or accompanied by other concerning symptoms. Fever management is important, but it may not warrant immediate provider notification unless it is severe or refractory to treatment.
c. Generalized rash over trunk:
A generalized rash can be associated with certain types of meningitis, such as meningococcal meningitis, and may indicate sepsis or disseminated infection. However, it may not always require immediate provider notification unless it is accompanied by other concerning symptoms or signs of systemic illness.
d. Report of photophobia:
Photophobia (sensitivity to light) is a common symptom of meningitis and is often reported by clients. While photophobia is significant in the context of meningitis, it may not require immediate provider notification unless it is severe or accompanied by other worrisome neurological symptoms.
Correct Answer is A
Explanation
a. "I will wear a surgical mask within 3ft of the client":
This statement is correct. Wearing a surgical mask within 3 feet of the client helps prevent the transmission of respiratory droplets from the client to the healthcare provider or others in close proximity.
b. "I will check that the room has a high-efficiency particulate air filtration system":
This statement is not directly related to implementing droplet precautions. While a high-efficiency particulate air (HEPA) filtration system can help improve air quality in a healthcare setting, it is not a standard requirement for implementing droplet precautions.
c. "I will wear an N95 respirator when providing care for the client":
This statement is not accurate for implementing droplet precautions for influenza. N95 respirators are used for airborne precautions, which are indicated for diseases transmitted by smaller droplet nuclei (e.g., tuberculosis). Surgical masks are typically sufficient for preventing the transmission of respiratory droplets during care for clients with influenza.
d. "I will assign the client to a room with positive airflow":
This statement is not appropriate for implementing droplet precautions. Positive airflow rooms are typically used for clients requiring airborne precautions to prevent the spread of infectious agents in the air. In the case of influenza, droplet precautions are sufficient, and assigning the client to a room with standard airflow is appropriate.
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