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 C

Explanation

Choice A reason: Taping to the cheek risks skin injury and tube displacement in kids. Abdominal securing is safer for gastrostomy stability and comfort.

Choice B reason: Extension tubes are for feeding, not routine site care. Attaching one now is premature, unrelated to maintaining the site itself.

Choice C reason: Securing to the abdomen prevents pulling or dislodgement of the gastrostomy tube. It’s a standard care step, ensuring stability and safety.

Choice D reason: Lubricant isn’t needed for site care; it may irritate skin. Clean, dry maintenance is preferred, making this an incorrect action.

A. Sleep apnea B. Paresthesias C. Disorientation D. Tonic-clonic seizures

Correct Answer is C

Explanation

Choice A reason: Sleep apnea isn’t an ECT effect; it’s a chronic breathing disorder. ECT may cause transient respiratory changes intra-procedure, not post. Scientifically, this lacks relevance, as 15-minute post-ECT findings focus on neurological recovery, not sleep-related respiratory patterns.

Choice B reason: Paresthesias (tingling) aren’t typical post-ECT; they suggest nerve issues unrelated to brain stimulation. ECT affects cognition, not peripheral sensation. Scientifically, this doesn’t align with expected acute neurological outcomes, which prioritize confusion over sensory disturbances.

Choice C reason: Disorientation is common 15 minutes post-ECT due to generalized seizure effects on brain function, impairing memory and awareness. Scientifically, this reflects transient postictal confusion, a standard response as neural activity normalizes, aligning with ECT’s cognitive impact.

Choice D reason: Tonic-clonic seizures occur during ECT, not after; post-procedure seizures suggest complications. At 15 minutes, recovery, not new seizures, is expected. Scientifically, this contradicts typical post-ECT progression, where brain stabilizes rather than re-enters convulsive states.

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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?

Nursing Test Bank

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