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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
A client who has anorexia nervosa is at risk for cardiac arrhythmias due to electrolyte imbalances, dehydration, and malnutrition. The client's statement of feeling their heart jumping in their chest indicates a possible irregular heartbeat that should be reported to the provider. Edema, temperature, and intake are not as urgent as heart rhythm in this case.
Correct Answer is B
Explanation
Phenelzine is a monoamine oxidase inhibitor (MAOI) that can cause a hypertensive crisis if taken with foods that contain tyramine, such as pepperoni pizza. The nurse should assess the client's blood pressure to monitor for signs of hypertension, such as headache, chest pain, or blurred vision.
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