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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is because assault is the threat of harm or unwanted contact, and battery is the actual physical contact without consent.
If the nurse administers the injection despite the client’s refusal, the nurse is violating the client’s autonomy and right to refuse treatment, and is committing both assault and battery.
Choice A is wrong because malice means having a deliberate intention to harm someone. The nurse may not have malice but may be acting out of ignorance or negligence.
Choice B is wrong because malpractice means a failure to meet a standard of care or conduct that causes injury or damage to a patient.
The nurse may be guilty of malpractice, but this is not the best term to describe the nurse’s action.
Choice C is wrong because negligence means a lack of care or skill that results in harm or injury.
The nurse may be negligent, but this is not the best term to describe the nurse’s action.
Correct Answer is B
Explanation
This is because acute pain is the most urgent and life-threatening problem for a client with myocardial infarction.
Acute pain indicates ongoing ischemia and tissue damage, which can lead to complications such as heart failure, arrhythmias, or cardiogenic shock. Therefore, relieving pain is the priority nursing diagnosis.
Choice A. Anxiety is wrong because anxiety is not a specific symptom of myocardial infarction and anxiety is due to the discomfort that happens due to activation of the sympathetic pathway which is good for survival.
Choice C. Knowledge deficit is wrong because knowledge deficit is not an immediate problem for a client with myocardial infarction.
Knowledge deficit can be addressed after the acute phase of the condition is over and the client is stable.
Choice D. Nausea and vomiting are wrong because nausea and vomiting are common symptoms of myocardial infarction, but they are not as urgent and life-threatening as acute pain.
Nausea and vomiting can be treated with antiemetics and fluids, but they do not affect the outcome of the condition as much as pain does.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.