A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should the nurse take?

Discuss the problem in a community meeting with the other clients on the unit present.

Escort the client to her room each time the nurse observes the client socializing with other clients.

Talk to the client and identify the specific limits that are required of the client's behavior.

Tell the other clients to ignore the client's lies

Answer and Explanation

The Correct Answer is C

A. Discuss the problem in a community meeting with the other clients on the unit present.

While open communication and community meetings can be valuable in certain situations, discussing a client's disruptive behavior in front of others may breach their privacy and dignity. It's important to address such matters privately and respectfully.

B. Escort the client to her room each time the nurse observes the client socializing with other clients.

This action might be seen as overly punitive and restrictive. Isolating the client based on their behavior without addressing the underlying issues doesn't promote a therapeutic approach to the situation.

C. Talk to the client and identify the specific limits that are required of the client's behavior.

This is the correct option. Talking to the client directly allows the nurse to address the behavior, express expectations, and set clear boundaries. This approach promotes open communication and gives the client a chance to understand how their actions are affecting others.

D. Tell the other clients to ignore the client's lies.

While it's important to encourage other clients to manage their reactions to disruptive behavior, simply telling them to ignore lies might not address the root cause of the issue. The nurse should aim to address the behavior itself and create an environment where all clients feel respected and safe.

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Free Nursing Study Resources

Correct Answer is ["2"]

Explanation

The nurse is preparing to administer benztropine 2 mg IM every 12 hours. The concentration of the available benztropine is 1 mg/mL.

To calculate the volume (mL) of the medication needed for the prescribed dose, you can use the formula:

Volume (mL) = Dose (mg) / Concentration (mg/mL)

Plugging in the values:

Volume (mL) = 2 mg / 1 mg/mL = 2 mL

So, the nurse should administer 2 mL of benztropine 1 mg/mL for each dose. Since we're looking for a whole number, we round to the nearest whole number, which is 2 mL.

A. The client will implement alternative strategies for managing anxiety. B. The client will acknowledge alcohol dependence and need for treatment. C. The client's withdrawal from alcohol will be managed without complications. D. The client will rebuild damaged interpersonal relationships.

Correct Answer is C

Explanation

A. The client will implement alternative strategies for managing anxiety.

While addressing anxiety is important for the overall well-being of the client, it may not be the highest priority in this context. The immediate physical safety of the client during alcohol withdrawal takes precedence over addressing anxiety.

B. The client will acknowledge alcohol dependence and need for treatment.

Recognizing alcohol dependence and the need for treatment is an important step, but it may not be the highest priority. It is more focused on the client's acceptance and understanding of their situation rather than addressing immediate health risks.

C. The client's withdrawal from alcohol will be managed without complications.

This is the correct answer. Managing alcohol withdrawal without complications is the highest priority goal in this scenario. Alcohol withdrawal can lead to severe physical symptoms, including seizures and delirium tremens, which can be life-threatening. Ensuring the safe and medically supervised management of withdrawal is crucial for the client's immediate well-being.

D. The client will rebuild damaged interpersonal relationships.

While repairing damaged relationships is important for the client's overall rehabilitation, it's not the highest priority in this context. Physical health and safety take precedence over addressing interpersonal issues.

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A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["2"]

Explanation

A nurse in a rehabilitation center is planning care for a newly admitted client who has a history of alcohol use disorder. Which of the following client goals is the highest priority?

Correct Answer is C

Explanation

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