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 ["A","B","C"]
Explanation
A. Blood pressure: The client's blood pressure has increased significantly from 132/68 mm Hg to 156/92 mm Hg. This elevation may indicate a physiological response to anxiety or agitation and requires monitoring and assessment for potential cardiovascular issues.
B. Hallucinations: The client reports auditory hallucinations ("the voices are coming back") and visual hallucinations (seeing a man in the corner of the room). These symptoms indicate a need for immediate intervention and further evaluation to ensure the client's safety and address their psychotic symptoms.
C. Insomnia: The client states they cannot sleep, which is a significant concern as lack of sleep can exacerbate psychiatric symptoms, impair functioning, and increase the risk of self-harm or harm to others. Addressing sleep disturbances is critical for the client's overall treatment and well-being.
D. Delusions: While delusions (e.g., believing that people are trying to hurt the client) are concerning and require monitoring, the hallucinations reported by the client are more acute and pose a more immediate risk to the client's safety. Therefore, hallucinations take priority over delusions in this situation.
E. Appetite: The client consumed 50% of their evening meal, which indicates some level of appetite. Although changes in appetite can be relevant in the context of mental health, it is not as urgent as the other findings related to blood pressure, hallucinations, and insomnia, which directly impact the client's immediate safety and well-being.
Correct Answer is D
Explanation
A. Analyze and interpret laboratory and medical imaging data: The Clinical Opiate Withdrawal Scale (COWS) does not focus on analyzing laboratory or imaging data. Instead, it is a clinical tool designed specifically for assessing withdrawal symptoms in clients experiencing opiate withdrawal.
B. Determine the client's risk of developing severe manifestations: While the COWS can provide insights into the severity of withdrawal symptoms, its primary purpose is not to assess the risk of severe manifestations. It is more focused on current symptoms rather than predicting future complications.
C. Identify genetic factors that influence opiate withdrawal: The COWS does not address genetic factors related to opiate withdrawal. It is a behavioral assessment tool that evaluates observable symptoms rather than delving into the genetic underpinnings of withdrawal responses.
D. Collect data on the severity of manifestations from withdrawal and treat accordingly: The primary function of the COWS is to systematically collect data on the severity of withdrawal symptoms. This information helps healthcare providers determine appropriate treatment interventions based on the client's current condition, ensuring that care is tailored to their specific needs during withdrawal.
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