During group therapy, the nurse observes that a client is pacing, agitated, and presenting with aggressive gestures. The client’s speech pattern is rapid, and affect is belligerent. Based on the observations, the nurse’s immediate priority of care is to:
Assist the staff in caring for the client in a controlled environment
Provide safety for the client and other clients on the unit
Provide the clients on the unit with a sense of comfort and safety
Offer the client a less stimulated area to calm down and gain control
The Correct Answer is B
Choice A reason:
While assisting the staff in caring for the client in a controlled environment is important, the immediate priority is to ensure safety. This choice does not directly address the immediate need to protect all clients from potential harm.
Choice B reason:
Providing safety for the client and other clients on the unit is the immediate priority. The client’s aggressive behavior poses a risk to themselves and others, and ensuring safety is the first step in managing the situation. This involves de-escalation techniques and possibly removing the client from the group setting to prevent harm.
Choice C reason:
Providing a sense of comfort and safety is important but secondary to ensuring immediate physical safety. The client’s aggressive behavior needs to be managed first to prevent any potential harm.
Choice D reason:
Offering the client a less stimulated area to calm down is a good strategy for de-escalation, but it comes after ensuring the immediate safety of all clients. The primary concern is to prevent any aggressive actions that could harm others.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
While assisting the staff in caring for the client in a controlled environment is important, the immediate priority is to ensure safety. This choice does not directly address the immediate need to protect all clients from potential harm.
Choice B reason:
Providing safety for the client and other clients on the unit is the immediate priority. The client’s aggressive behavior poses a risk to themselves and others, and ensuring safety is the first step in managing the situation. This involves de-escalation techniques and possibly removing the client from the group setting to prevent harm.
Choice C reason:
Providing a sense of comfort and safety is important but secondary to ensuring immediate physical safety. The client’s aggressive behavior needs to be managed first to prevent any potential harm.
Choice D reason:
Offering the client a less stimulated area to calm down is a good strategy for de-escalation, but it comes after ensuring the immediate safety of all clients. The primary concern is to prevent any aggressive actions that could harm others.
Correct Answer is A
Explanation
Choice A reason:
Extrapyramidal symptoms (EPS) are a common adverse effect of haloperidol, a first-generation antipsychotic. EPS includes symptoms such as tremors, rigidity, bradykinesia, and tardive dyskinesia. These symptoms result from the drug’s effect on the dopaminergic pathways in the brain.
Choice B reason:
Intractable hiccups are not a known adverse effect of haloperidol. This symptom is more commonly associated with other conditions or medications, but not with antipsychotic drugs like haloperidol.
Choice C reason:
Excessive salivation is not typically associated with haloperidol. Antipsychotic medications can cause dry mouth rather than excessive salivation. This symptom is more commonly seen with other medications or conditions.
Choice D reason:
Fever is not a common adverse effect of haloperidol. While fever can occur in the context of neuroleptic malignant syndrome (a rare but serious reaction to antipsychotics), it is not a typical side effect of haloperidol use. The primary concern with haloperidol is the development of extrapyramidal symptoms.
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