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 ["B","E"]
Explanation
b. Ensure the chest tube remains below the level of the client's chest.
e. Reinforce loose dressing around the tube.
When managing a chest tube, it is important for the nurse to ensure that the chest tube remains below the level of the client's chest¹. This helps to prevent air from entering the pleural space and allows for proper drainage of fluid. The nurse should also reinforce any loose dressing around the tube to maintain a secure seal¹.
Correct Answer is D
Explanation
Atorvastatin is a medication used to lower cholesterol levels in the blood. One of the potential adverse effects of atorvastatin is myopathy, a condition characterized by muscle pain, weakness, and tenderness. In severe cases, myopathy can progress to rhabdomyolysis, a potentially life-threatening condition in which muscle breakdown products are released into the bloodstream and can cause kidney damage.
Therefore, the nurse should instruct the client to monitor for muscle pain, weakness, or tenderness and report these symptoms to the healthcare provider immediately. Hypoglycemia, palpitations, and daytime drowsiness are not commonly associated with atorvastatin use and would not require immediate reporting to the healthcare provider.
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