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. Stimulants: While stimulants can cause symptoms such as increased energy, agitation, and paranoia, the specific combination of paranoia, visual disturbances (such as talking to the wall), and altered perception is more indicative of hallucinogen use.
B. Anabolic steroids: Anabolic steroids primarily affect physical strength and body composition, and while they can lead to aggressive behavior, they do not typically cause the acute symptoms of paranoia and visual hallucinations seen in this client.
C. Hallucinogens: The symptoms described, including paranoia, dizziness, vomiting, and visual disturbances (evidenced by the client talking to the wall), are characteristic of hallucinogen use. Hallucinogens can induce altered perceptions and significant changes in mood and thought processes, leading to behaviors like the ones exhibited by the client.
D. Opioids: Opioids generally cause sedation, respiratory depression, and a sense of euphoria, but they do not typically produce paranoia or hallucinations. The symptoms presented by the client do not align with opioid intoxication.
Correct Answer is C
Explanation
A. Historical: Historical data refers to past medical or substance use history but does not specifically relate to the client’s current account of their substance use. While this information is relevant, it is not the primary type of data being collected in this instance.
B. Objective: Objective data consists of measurable and observable information, such as vital signs, physical examination findings, or laboratory results. The client's account of their cocaine use is not an objective measure but rather a personal statement reflecting their experience.
C. Subjective: The client's statement about using cocaine daily for the past 6 months is subjective data. It is based on the client's personal experiences and perceptions, which are important for understanding their substance use pattern and informing treatment planning.
D. Secondary: Secondary data refers to information obtained from sources other than the client, such as family members, previous medical records, or other healthcare providers. Since the information is coming directly from the client, it does not qualify as secondary data.
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.