A nurse is working with a client who becomes combative and threatens other clients and staff. Which of the following actions should the nurse take?
Stand in front of the client to block them from others in the room.
Apply restraints according to the facility's standing order.
Ensure there are enough staff members available for assistance.
Obtain a PRN prescription for restraints from the provider.
The Correct Answer is C
Choice A reason: Standing in front risks escalation and injury; de-escalation needs space. Safety protocol prioritizes staff positioning away from a combative client’s reach.
Choice B reason: Standing orders for restraints vary; immediate application skips assessment. Ensuring staff support first allows safer, assessed intervention per guidelines.
Choice C reason: Adequate staff ensures safe de-escalation or restraint if needed. It’s the priority, reducing risk to all in a combative situation effectively.
Choice D reason: PRN restraint orders follow de-escalation attempts; staff availability precedes this. Immediate safety via numbers is critical before seeking prescriptions here.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Music therapy reduces pain perception but doesn’t eliminate breakthrough pain needs. Scientifically, it’s an adjunct, not a replacement, for analgesics, as severe pain signals persist despite auditory distraction, indicating misunderstanding of its supplementary role in hospice care.
Choice B reason: Discontinuing music when unresponsive overlooks its passive benefits, like comfort, even in unconscious states. Scientifically, auditory stimuli can soothe, suggesting continued use, not cessation, misaligning with hospice goals for holistic pain management.
Choice C reason: Increasing alertness contradicts music therapy’s calming effect in hospice, aimed at relaxation, not stimulation. Scientifically, it lowers arousal to ease pain perception, not heighten awareness, showing a misgrasp of its palliative intent.
Choice D reason: Music distracts from pain by engaging the brain’s auditory cortex, reducing focus on nociceptive signals. Scientifically, this aligns with gate control theory, where non-painful stimuli mitigate pain perception, reflecting accurate understanding of its role in hospice care.
Correct Answer is B
Explanation
Choice A reason: Exercising 15 minutes twice weekly is below the 150-minute weekly guideline for hypertension. Scientifically, inadequate aerobic activity fails to lower blood pressure effectively, showing misunderstanding of lifestyle changes needed for cardiovascular health improvement.
Choice B reason: Reducing salt to 2 grams (2000 mg) aligns with hypertension guidelines, lowering fluid retention and pressure. Scientifically, this reflects sodium’s role in vascular tone, indicating correct understanding of dietary impact on mild hypertension management.
Choice C reason: A goal of 130/84 mmHg exceeds the 120/80 target for mild hypertension control. Scientifically, this misaligns with optimal blood pressure reduction, suggesting incomplete grasp of therapeutic lifestyle outcomes per evidence-based standards.
Choice D reason: Two glasses of wine nightly exceeds moderation (one drink), raising blood pressure. Scientifically, excess alcohol counters hypertension control, as it vasoconstricts, indicating misunderstanding of lifestyle limits for cardiovascular health maintenance.
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