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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Hypersomnia causes excessive sleep, not delirium’s acute confusion. It’s unrelated to the restlessness and disorientation seen in this client’s presentation.
Choice B reason: High cholesterol affects vessels, not acute brain function. It’s a chronic risk, not a trigger for delirium’s sudden cognitive shift here.
Choice C reason: UTIs in older adults often cause delirium via systemic inflammation and toxins. This matches the client’s disorientation and restlessness as a risk.
Choice D reason: Amyloid plaque links to Alzheimer’s, a chronic condition. Delirium is acute; plaque doesn’t explain the sudden onset in this scenario.
Correct Answer is C
Explanation
Choice A reason: Living wills can be updated anytime, not fixed. This misinformation contradicts legal flexibility, key for clients to understand in directives.
Choice B reason: Surrogates needn’t be family; any trusted person qualifies. Mandating family limits choice, misrepresenting the broad options in directive planning.
Choice C reason: A surrogate decides when the client can’t, per advance directives. This accurately informs about proxy roles, essential for incapacity planning.
Choice D reason: Attorneys aren’t required; forms suffice legally in most states. This overcomplicates surrogacy, deterring clients from completing directives unnecessarily.
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