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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Lowering the window shade in the client’s room does not directly contribute to fall prevention. It might even increase the risk if it makes the room darker and the client can’t see clearly.

Choice B rationale:

Using a vest restraint is not the best option. Restraints should be used as a last resort, and only if less restrictive interventions have been ineffective.

Choice C rationale:

Placing the client in a room close to the nurses’ station allows for more frequent observation and quicker response if the client needs assistance, reducing the risk of falls.

Choice D rationale:

While recreational therapy can be beneficial for clients with dementia, it does not directly address the issue of fall prevention.

A. Hypomagnesemia B. Hypokalemia. C. Muscle wasting. D. Lanugo.

Correct Answer is B

Explanation

Choice A rationale:

Hypomagnesemia is not a common finding in clients with bulimia nervosa.

Choice B rationale:

Hypokalemia is a common finding due to purging behaviors, such as self-induced vomiting or misuse of laxatives, which can lead to loss of potassium.

Choice C rationale:

Muscle wasting is more commonly associated with anorexia nervosa, not bulimia nervosa.

Choice D rationale:

Lanugo, or fine body hair, is also more commonly associated with anorexia nervosa, not bulimia nervosa.

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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?.

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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?.