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 C
Explanation
c. Diminished pulses on the affected extremity. This finding may indicate compromised circulation, which is
a serious complication that requires immediate intervention.
Option a. Ecchymosis on the inner left thigh may be a concerning finding, but it is not as urgent as diminished pulses. Ecchymosis may be a result of trauma during cast application, and may resolve on its own.
Option b. One fingerbreadth of space between the cast and the skin is a normal finding and indicates that the cast is not too tight.
Option d. Client report of muscle spasms of the left leg is a common complaint in clients with casts and may
be addressed with medication or other interventions, but it is not as urgent as diminished pulses. Therefore, the priority finding in this scenario is c. Diminished pulses on the affected extremity.
Correct Answer is A
Explanation
Cotton underwear is recommended for individuals with UTIs because it allows better air circulation and helps keep the genital area dry. This can prevent the growth of bacteria and reduce the risk of further infection.
Drink orange juice daily for 3 to 4 weeks: While hydration is important for overall health, there is no specific recommendation to drink orange juice or any specific juice for the treatment of a UTI. It is generally recommended to increase fluid intake, particularly water, to help flush out the bacteria from the urinary system.
Take the prescribed antibiotic until manifestations are gone: This instruction is correct. It is important for the client to take the full course of the prescribed antibiotic as directed by their healthcare provider, even if symptoms improve before completing the entire course. This helps ensure complete eradication of the bacteria and reduces the risk of antibiotic resistance.
Restrict fluid intake to 1 L per day: Adequate fluid intake is important for UTI management as it helps flush out bacteria from the urinary system. Restricting fluid intake to 1 liter per day is not recommended and may not provide sufficient hydration. It is generally advised to drink plenty of water and other fluids throughout the day.
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