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: Swallowing isn’t an option for chewable isosorbide; it’s designed for sublingual absorption. This advice is incorrect and won’t address vasodilatory headache effects.
Choice B reason: Discontinuing isosorbide risks angina exacerbation in cardiac patients. Headaches are tolerable side effects, so stopping isn’t advised without provider input.
Choice C reason: Empty stomach intake doesn’t reduce isosorbide’s vasodilatory headaches. Timing doesn’t alter its nitrate-induced vessel dilation, making this ineffective advice.
Choice D reason: Headaches from isosorbide’s vasodilation typically subside with tolerance over time. This reassures the client, aligning with expected nitrate therapy adaptation.
Correct Answer is C
Explanation
Choice A reason: Wiping yellow crusts disrupts healing; they’re normal post-Plastibell exudate. This shows misunderstanding, as crusts should remain until the ring detaches naturally.
Choice B reason: Snug diapers risk ring displacement or irritation in Plastibell care. Loose fitting is advised, so this indicates a lack of proper technique understanding.
Choice C reason: Applying pressure with gauze controls minor bleeding, a correct response in Plastibell care. It shows understanding of managing complications until medical help is sought.
Choice D reason: Antibiotic ointment isn’t routine for Plastibell; petroleum jelly is used instead. This reflects incorrect care knowledge, potentially causing irritation or infection.
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