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. "I should exercise for 15 minutes two times per week." B. "I should decrease my salt intake to 2 grams per day." C. "I will set my blood pressure goal at 130 over 84." D. "I can have two glasses of wine with dinner."

Correct Answer is B

Explanation

Choice A reason: Exercising 15 minutes twice weekly is below the 150-minute weekly guideline for hypertension. Scientifically, inadequate aerobic activity fails to lower blood pressure effectively, showing misunderstanding of lifestyle changes needed for cardiovascular health improvement.

Choice B reason: Reducing salt to 2 grams (2000 mg) aligns with hypertension guidelines, lowering fluid retention and pressure. Scientifically, this reflects sodium’s role in vascular tone, indicating correct understanding of dietary impact on mild hypertension management.

Choice C reason: A goal of 130/84 mmHg exceeds the 120/80 target for mild hypertension control. Scientifically, this misaligns with optimal blood pressure reduction, suggesting incomplete grasp of therapeutic lifestyle outcomes per evidence-based standards.

Choice D reason: Two glasses of wine nightly exceeds moderation (one drink), raising blood pressure. Scientifically, excess alcohol counters hypertension control, as it vasoconstricts, indicating misunderstanding of lifestyle limits for cardiovascular health maintenance.

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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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