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
Explanation
A. Increased hemoglobin:
Clients with nephrotic syndrome may have anemia due to loss of erythropoietin or nutritional deficiencies, not increased hemoglobin.
B. Hyperalbuminemia:
Nephrotic syndrome is characterized by hypoalbuminemia due to massive urinary protein loss.
C. Hypolipidemia:
Clients often develop hyperlipidemia as the liver tries to compensate for protein loss by increasing lipoprotein production.
D. Proteinuria:
Massive proteinuria is the hallmark of nephrotic syndrome, often exceeding 3.5 g/day.
Correct Answer is C
Explanation
A. Number scale
Requires verbal communication and abstract reasoning, not appropriate for advanced dementia.
B. Color scale
Also requires cognitive recognition that may be impaired in dementia.
C. Behavioral pain scale
This scale assesses pain using facial expression, body movements, and vocalizations.
D. Pieces of pain scale
This is generally used for pediatric clients, not those with dementia.
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