A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?

Stop the newly licensed nurse from administering the medication.

Demonstrate how to verbally de-escalate the situation.

Discuss the purpose of the medication with the client.

Assess the need for physical restraints.

Answer and Explanation

The Correct Answer is B

A. Stop the newly licensed nurse from administering the medication – While it is important to prevent the administration of medication against the client's will, the focus should initially be on de-escalation to address the client's refusal.

B. Demonstrate how to verbally de-escalate the situation – This is the most appropriate first action. De-escalation techniques can help calm the client and create a dialogue, potentially leading to a willingness to discuss the medication and its benefits.

C. discussing the medication's purpose, is also secondary to honoring the client's current refusal.

D. assessing the need for restraints, would be inappropriate without first stopping the medication administration and could escalate the situation. Therefore, the first and most critical action is to stop the medication administration.

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Correct Answer is A

Explanation

Choice A reason:

Significant weight loss in a patient with major depressive disorder is a red flag for clinicians. It can signify a high risk of complications, including malnutrition, electrolyte imbalance, and weakened immunity. In the context of depression, it may also reflect a lack of self-care or even suicidal tendencies, which require immediate attention.

Choice B reason:

While markedly neglected hygiene is concerning and indicative of a patient's inability to perform daily self-care activities, it is not typically considered an immediate life-threatening issue. However, it does warrant intervention to prevent potential secondary infections or complications.

Choice C reason:

Psychomotor retardation is a symptom that can manifest in major depressive disorder, characterized by slowed physical movements and cognitive processing. Although it impacts the quality of life and daily functioning, it is not usually a direct indicator of an acute life-threatening condition.

Choice D reason:

Poor problem-solving skills are part of the cognitive symptoms of depression, affecting a patient's ability to manage daily tasks and make decisions. While this can significantly impact a patient's life, it is not as urgent as significant weight loss, which can have immediate physical health consequences.

A. Sore throat B. Heart rate 104/min C. Nausea D. Random blood glucose 130 mg/dL

Correct Answer is A

Explanation

This finding could indicate agranulocytosis, a potentially life threatening adverse effect of clozapine that causes a severe decrease in white blood cells and increases the risk of infection. The other findings are also important to monitor, but they are not as critical as sore throat.

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A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who has major depressive disorder. Which of the following findings obtained during the initial assessment is the priority to report to other disciplines?

Correct Answer is A

Explanation

What is the priority finding to report to the provider for a client who has schizophrenia and is taking clozapine?

Correct Answer is A

Explanation

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