A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively.
Which action is the priority?

Maintain trust and avoid behaviors that may increase agitation.

Order the client to go to their room & alert security.

Tell the client to sit down or risk isolation and loss of privileges.

Sedate the client after collecting a lithium level.

Answer and Explanation

The Correct Answer is A

Maintain trust and avoid behaviors that may increase agitation. This is because the client is likely experiencing a manic episode, which is characterized by increased activity, rapid speech, and decreased need for sleep. The nurse should use a calm and supportive approach, provide a safe and structured environment, and avoid confrontation or criticism.

Choice B is wrong because ordering the client to go to their room and alerting security would escalate the situation and violate the client’s rights.

Choice C is wrong because telling the client to sit down or risk isolation and loss of privileges would be threatening and punitive, which could increase the client’s agitation and anger.

Choice D is wrong because sedating the client after collecting a lithium level would be premature and inappropriate without a physician’s order and without assessing the client’s vital signs, mental status, and medication history. Lithium is a mood stabilizer that can cause toxicity if the level is too high.

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Correct Answer is A

Explanation

“Have you had thoughts about killing yourself?” This is the best response because it directly assesses the client’s suicidal risk and shows empathy and concern.

The other choices are wrong because:

Choice B. “What can’t you go on anymore?” This is a vague and open-ended question that does not address the client’s immediate safety or emotional state.

Choice C. “Don’t think like that.

It’s not true!” This is a dismissive and invalidating response that does not acknowledge the client’s feelings or offer support.

Choice D. “Have you talked to your doctor about these feelings?” This is a deferring and avoiding response that does not explore the client’s situation or provide any intervention.

A. Teaching handouts are written on an eighth grade reading level. B. Using teach back method to assess understanding. C. The teaching plan is based on nutrition, medications, and safety. D. Websites, video chats, and cell phone applications are introduced for learning.

Correct Answer is B

Explanation

Using teach back method to assess understanding. This method involves asking the client to repeat back the information or demonstrate the skill that was taught, which helps to evaluate their comprehension and retention.

It also allows the nurse to correct any misunderstandings and reinforce key points.

Choice A is wrong because teaching handouts are written on an eighth grade reading level may not be appropriate for older adult clients who may have lower literacy levels or cognitive impairments. The nurse should use simple, common language and large-print handouts that reflect the verbal information presented.

Choice C is wrong because the teaching plan is based on nutrition, medications, and safety may not address the individual needs and preferences of the older adult clients. The nurse should consider the preadmission functional abilities, health goals, and learning styles of each client when developing the plan of care.

Choice D is wrong because websites, video chats, and cell phone applications are introduced for learning may not be suitable or accessible for older adult clients who may have limited technology skills or sensory impairments. The nurse should use visual aids, face-to-face communication, and written instructions to enhance learning.

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A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively. Which action is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively.
Which action is the priority?