A client is becoming increasingly agitated, anxious, and tense.
The nurse notes a clenched jaw and a change in the pitch of the client's voice.
Which of the following interventions should the nurse implement first?.
Obtain a prescription for haloperidol.
Take the client to the seclusion room.
Verbally de-escalate the client.
Place the client in restraints.
The Correct Answer is C
Choice A rationale:
Obtaining a prescription for haloperidol is not the first intervention the nurse should implement. Medication should be considered only after non-pharmacological interventions have been attempted.
Choice B rationale:
Taking the client to the seclusion room is not the first intervention the nurse should implement. Seclusion should be used only as a last resort when all other interventions have failed and the client is a danger to themselves or others.
Choice C rationale:
Verbally de-escalating the client is the first intervention the nurse should implement. This involves using calm, clear communication to help the client regain control of their emotions.
Choice D rationale:
Placing the client in restraints is not the first intervention the nurse should implement. Restraints should be used only as a last resort when all other interventions have failed and the client is a danger to themselves or others.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Discussing childhood memories during group therapy is a key component of reminiscence therapy. It helps older adults recall past experiences and can improve their mood and cognitive function.
Choice B rationale:
Playing board games can enhance cognition, but it’s not specific to reminiscence therapy.
Choice C rationale:
Making a unit calendar promotes orientation, but it’s not part of reminiscence therapy.
Choice D rationale:
Encouraging thought-stopping can help block undesirable thoughts, but it’s not a strategy used in reminiscence therapy.
Correct Answer is ["A","B","C","D","E","F","G"]
Explanation
The findings that require immediate follow-up are: Client confused and agitated: This could indicate a neurological issue or other serious condition that needs immediate attention.
Appearance is disheveled: This could suggest neglect or other issues that need to be addressed.
Mucous membranes dry: This could indicate dehydration which can be serious if not addressed promptly. Client states “Can you ask that person to leave my room?” Client is pointing to an empty chair: This could indicate hallucinations or other mental health concerns that need immediate attention.
Temperature 38.6°C (101.5°F): This is a fever and could indicate an infection or other medical condition that needs immediate attention.
Blood pressure 158/96 mm Hg: This is high and could indicate hypertension or other cardiovascular issues that need immediate attention.
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