A nurse on a mental health unit observes a client yelling at another client. Which of the following actions should the nurse take first?
State expectations for the client's behavior.
Request security personnel restrain the client.
Place the client in seclusion.
Debrief staff members about the conflict.
The Correct Answer is A
The correct answer is Choice A.
Choice A rationale: By stating expectations for the client’s behavior, the nurse is addressing the immediate situation and setting clear boundaries. This intervention allows the nurse to assertively communicate with the client, reminding them of appropriate behavior and potentially diffusing the situation1.
Choice B rationale: Requesting security personnel to restrain the client should be a last resort, used only when the client poses a significant risk to themselves or others and all other de-escalation techniques have failed. Restraint can be traumatic and has potential physical and psychological risks.
Choice C rationale: Placing the client in seclusion is another measure that should be used sparingly and only when necessary for the safety of the client or others. It’s important to try less restrictive measures first, such as verbal de-escalation techniques or offering a quiet, private space where the client can regain control.
Choice D rationale: Debriefing staff members about the conflict is an important step, but it should not be the first action. The immediate priority is to ensure the safety of all clients and to de-escalate the situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Dementia is a condition characterized by a decline in cognitive function that affects a person's ability to perform activities of daily living (ADLs). Memory loss is a common symptom of dementia, particularly in the early stages. Memory loss can disrupt a person's ability to carry out tasks they were previously able to do independently, such as dressing, bathing, and eating. Therefore, option A is the correct answer.
Option b, catatonia, is a condition characterized by a lack of movement or activity, which is not typically associated with dementia.
Option c, illusions, involve a misinterpretation of sensory information and may occur in some forms of dementia but are not a defining feature.
Option d, pressured speech, is a symptom commonly associated with mania or bipolar disorder but is not typically seen in dementia.
Correct Answer is D
Explanation
Dry, itchy skin is a common concern in older adults, especially during the winter months or in dry environments. Increasing the humidity in the client's environment can help alleviate dryness and itching. Placing a humidifier in the client's room will add moisture to the air and help prevent excessive drying of the skin. It is important to ensure that the humidifier is clean and well-maintained to avoid the growth of bacteria or mould.
Encouraging the client to bathe frequently may further dry out the skin, so it is not recommended. Similarly, applying powder to the skin may exacerbate dryness and should be avoided. Adding moisturizing oil to the bath water may provide temporary relief, but a humidifier will have a more consistent and long-lasting effect on the client's environment.
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