An adult patient assaulted another patient and was then restrained. One hour later, which statement by the restrained patient requires the nurse's immediate attention?

"I hate all of you!"

"The other patient started the fight."

"You wait until I tell my lawyer."

"My fingers are tingly."

Answer and Explanation

The Correct Answer is D

A. "I hate all of you!" –This reflects the patient’s anger and hostility, which is expected after being restrained. While it requires therapeutic communication, it does not signal a medical emergency.

B. "The other patient started the fight." – This statement is defensive and attempts to shift blame. Although it provides insight into the patient’s thought process, it is not urgent from a physiological standpoint.

C. "You wait until I tell my lawyer." – This reflects frustration and a threat of legal action. It is important for documentation and de-escalation but does not require immediate clinical intervention.

D. "My fingers are tingly." – This is the highest priority because it indicates impaired circulation or nerve compression related to the restraints. Tingling, numbness, coolness, or pallor are warning signs that restraints are too tight or causing neurovascular compromise. This can lead to permanent injury if not corrected promptly.

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Correct Answer is A

Explanation

A. Clients experiencing grandiose thinking during acute mania often have inflated self-esteem and unrealistic ideas of ability or importance, making controlling or monitoring their thoughts a priority nursing outcome.

B. While sleep disturbances are common in mania, this outcome does not directly address grandiose thinking.

C. Increased engagement in the environment may occur, but it is not the primary expected outcome for controlling grandiose thoughts.

D. Optimism may be present, but grandiosity involves exaggerated self-perceptions rather than realistic optimism.

A. Obtain a blood specimen. B. Implement seizure precautions. C. Perform a neurological exam D. Insert an intravenous (IV) access site.

Correct Answer is B

Explanation

A. While laboratory tests are important for assessing electrolyte imbalances and liver function, they are not the immediate priority in acute alcohol withdrawal.

B. Acute alcohol withdrawal can rapidly lead to seizures and delirium tremens, which are life-threatening. Patient safety and prevention of injury are the priority.

C. Neurological assessment is important, but first ensuring the client’s safety from potential seizures takes precedence.

D. IV access is necessary for fluid or medication administration, but it follows implementing immediate safety measures.

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An adult patient assaulted another patient and was then restrained. One hour later, which statement by the restrained patient requires the nurse's immediate attention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which outcome is expected for a client experiencing grandiose thinking associated with acute mania?

Correct Answer is A

Explanation

A nurse in an emergency department is caring for a client who is experiencing acute alcohol withdrawal. Which of the following actions should the nurse first take?

Correct Answer is B

Explanation

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