A nurse on a mental health unit is assisting with the care of a client.
The nurse is continuing to assist with the care of the client. Select the four actions the nurse should take.
Ask the provider for a PRN prescription for restraints.
Administer diazepam when the client exhibits anxiousness.
Place the client in a room near the nurse's station.
Determine if the client is experiencing command hallucinations.
Establish clear limits for expected behaviors.
Correct Answer : B,C,D,E
A. Ask the provider for a PRN prescription for restraints: Restraints should only be used as a last resort when there is an imminent risk of harm to the client or others. In this situation, it is essential to first attempt to manage the client's anxiety and behavior through de-escalation strategies and appropriate interventions.
B. Administer diazepam when the client exhibits anxiousness: Diazepam can help manage anxiety and agitation, which is crucial for the client's safety and comfort. Monitoring for signs of anxiety allows for timely intervention with the prescribed medication.
C. Place the client in a room near the nurse's station: Keeping the client close to the nurse's station allows for increased monitoring and ensures that staff can respond quickly if the client's behavior escalates. This helps maintain safety for both the client and others on the unit.
D. Determine if the client is experiencing command hallucinations: Assessing for command hallucinations is important, especially given the client's recent aggressive behavior. Understanding the presence of such hallucinations can guide the treatment plan and safety measures.
E. Establish clear limits for expected behaviors: Setting clear expectations for behavior helps the client understand acceptable conduct and promotes a safer environment. This can be particularly important for clients with paranoid personality disorder who may struggle with interpersonal relationships.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. To ensure the client participates in a walk with staff on a daily basis: While regular physical activity can be beneficial, this goal focuses more on physical activity rather than addressing the underlying issues related to medication adherence and relapse prevention.
B. To keep the client's environment calm and with minimal daily stimuli: Creating a calm environment can help manage symptoms, but it is a more immediate concern rather than a long-term goal focused on the client's overall management and understanding of their condition.
C. To develop and acknowledge understanding of a relapse plan prior to discharge: This goal is crucial for the client's long-term recovery and management of their condition. By understanding their relapse plan, the client can identify triggers, recognize early warning signs of relapse, and engage in proactive strategies to maintain their mental health after discharge.
D. To be reoriented to their current environment as needed: While reorientation may be necessary for managing acute symptoms, it does not address long-term strategies for preventing relapse or promoting the client's overall well-being. This goal is more focused on immediate needs rather than long-term outcomes.
Correct Answer is B
Explanation
A. Naloxone: Naloxone is an opioid antagonist used to reverse opioid overdoses. It is not indicated for alcohol withdrawal and does not address the symptoms associated with this condition.
B. Benzodiazepines: Benzodiazepines are commonly prescribed to manage alcohol withdrawal symptoms. They help reduce anxiety, prevent seizures, and alleviate autonomic instability during the withdrawal process, making them the first-line treatment in such cases.
C. Diphenhydramine: Diphenhydramine is an antihistamine that may be used for allergy symptoms or as a sleep aid. It is not indicated for managing alcohol withdrawal symptoms and does not address the critical issues associated with this condition.
D. Methadone: Methadone is a medication used for opioid dependence and is not appropriate for treating alcohol withdrawal. It is specifically designed to manage opioid addiction and does not have a role in alcohol withdrawal management.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.