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: Counterpressure helps back labor pain, not cesarean incision pain. It targets muscle tension, not surgical site discomfort, which stems from tissue trauma. For a day-old cesarean, this misaligns with pain source, lacking scientific support for reducing abdominal strain during position changes post-surgery.

Choice B reason: Limiting position changes reduces mobility, risking complications like thrombosis or stiffness post-cesarean. Movement aids recovery, and pain management should facilitate, not hinder, it. This advice contradicts evidence-based practice promoting early ambulation, making it an ineffective and potentially harmful nonpharmacological strategy.

Choice C reason: Splinting the incision with a pillow supports the abdominal wall, reducing strain on sutures during movement. This decreases pain from muscle stretching post-cesarean, aligning with scientific principles of mechanical support, making it an effective, evidence-based nonpharmacological method to manage discomfort safely.

Choice D reason: Patterned breathing aids labor or anxiety, not surgical pain. It distracts from discomfort but does not address physical strain on the cesarean incision during position changes. Lacking direct mechanical relief, it’s less effective scientifically compared to splinting for this specific postoperative pain context.

A. Take the medication with calcium-fortified orange juice. B. Take the medication with crackers. C. Take the medication and then lay down for 30 min. D. Take the medication with an antacid.

Correct Answer is B

Explanation

Choice A reason: Calcium-fortified juice binds doxycycline, reducing absorption via chelation in the gut. Scientifically, tetracyclines like doxycycline lose efficacy with divalent cations, worsening nausea without treating chlamydia, making this counterproductive to therapeutic goals and pharmacokinetics.

Choice B reason: Taking doxycycline with crackers minimizes gastric irritation, reducing nausea while maintaining absorption. Scientifically, light food buffers the stomach without significantly impairing tetracycline bioavailability, aligning with evidence-based advice to improve tolerability and adherence in chlamydia treatment.

Choice C reason: Lying down after doxycycline risks esophageal irritation or reflux, worsening nausea. Scientifically, upright posture post-dose prevents drug stasis, which can cause ulcers, making this contrary to safe administration practices for tetracyclines per clinical guidelines.

Choice D reason: Antacids with magnesium or aluminum bind doxycycline, decreasing absorption and efficacy. Scientifically, this interaction undermines chlamydia treatment, as tetracyclines require an acidic environment for uptake, rendering this incompatible with therapeutic success and worsening outcomes.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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