A nurse on a mental health unit is caring for a client in the day room who is becoming increasingly agitated. Which of the following actions should the nurse take?
Check the client's medical record for a prescription for physical restraints.
Speak to the client in a low, calm voice.
Ask security personnel to escort the client to their room.
Stand directly in front of the client and instruct them to sit down.
The Correct Answer is B
A. Check for prescription for restraints.
Restraints are a last resort; nurse should attempt de-escalation first.
B. Speak to the client in a low, calm voice.
De-escalation and calm communication are first-line responses to agitation.
C. Ask security personnel to escort the client.
Escalates tension and should not be first-line.
D. Stand directly in front of the client and instruct them to sit.
Standing in front of an agitated person can be confrontational and may provoke aggression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D,A,B,C
Explanation
Correct answer: D, A, B, C
A. Review the client's pertinent medical history:
Part of Background – provides context about the client’s past conditions and relevant history.
B. State the client's most recent vital signs:
Part of Assessment – offers current clinical data needed for informed decision-making.
C. Discuss suggestions for continuing the client's care:
Part of Recommendation – includes advice or action items to guide the next steps in the care plan.
D. Provide a brief description of the client's diagnosis:
Part of Situation – the starting point, stating why the report is being given.
Correct Answer is B
Explanation
A. 60 mL catheter-tip syringe
More appropriate for enteral tube feeding, not general dysphagia management.
B. Yankauer suction device
Needed in case the client aspirates or has trouble managing oral secretions.
C. pH strip
Used to verify placement of NG tubes, not specific to dysphagia precautions.
D. Padded tongue blade
Used for seizure precautions-not relevant here unless seizure risk exists.
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