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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Elevated ammonia relates to liver failure, not pancreatitis. Pancreatitis involves pancreatic enzyme leakage, not nitrogen metabolism. Scientifically, ammonia rises in hepatic encephalopathy, lacking relevance to pancreatic inflammation, making this an incorrect marker for the condition.

Choice B reason: Elevated lipase is a hallmark of pancreatitis, as inflamed pancreatic acinar cells release this enzyme into blood. Scientifically, it’s a specific diagnostic indicator, rising with tissue damage, aligning with pancreatitis pathophysiology for accurate clinical identification.

Choice C reason: Prolonged PT/INR reflects coagulopathy, often liver-related, not pancreatitis unless complicated by disseminated intravascular coagulation. Scientifically, this isn’t a primary marker, as pancreatitis targets digestion, not clotting, making it less expected in typical cases.

Choice D reason: Decreased albumin suggests chronic liver disease or malnutrition, not acute pancreatitis. Pancreatitis doesn’t directly impair protein synthesis. Scientifically, albumin drops over time, not acutely, misaligning with pancreatitis’s rapid inflammatory onset and diagnostic profile.

A. Epigastric pain B. Seizure activity C. Sudden loss of vision in one eye D. Pain radiating down the left arm

Correct Answer is C

Explanation

Choice A reason: Epigastric pain suggests GI issues, not TIAs. In hypertension, TIAs affect cerebral vessels, causing neurological deficits, not abdominal symptoms like this.

Choice B reason: Seizures stem from cortical irritation, not typical TIA vascular occlusion. Hypertension-related TIAs produce transient deficits, not convulsive activity usually.

Choice C reason: Sudden monocular vision loss (amaurosis fugax) is a classic TIA sign in hypertension. It reflects temporary retinal artery occlusion, resolving quickly.

Choice D reason: Left arm pain mimics cardiac issues, not TIAs. Hypertension TIAs target brain circulation, causing focal deficits, not referred pain patterns.

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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?

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