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:
Acknowledging an inability to control drinking is the first step in many recovery models, including the 12-step program of Alcoholics Anonymous. This step involves admitting that alcohol has taken over one’s life.
Choice B rationale:
Agreeing to a prescription for an alcohol use deterrent can be a part of the recovery process, but it is not typically the first step.
Choice C rationale:
Incorporating a form of spirituality into daily life can be a part of the recovery process for some individuals, but it is not typically the first step.
Choice D rationale:
Forming a close support network is crucial in the recovery process, but it comes after acknowledging the problem.
Correct Answer is B
Explanation
Choice A rationale:
This statement is incorrect. People with bulimia nervosa often consume large amounts of food in a short period of time, known as binge eating.
Choice B rationale:
This statement is correct. Despite the binge-purge cycle, individuals with bulimia nervosa can maintain an average or ideal body weight, making the disorder less noticeable.
Choice C rationale:
This statement is incorrect. While self-induced vomiting is a common method of purging in bulimia nervosa, other methods such as excessive exercise, fasting, or misuse of laxatives, diuretics, or enemas can also be used.
Choice D rationale:
This statement is incorrect. While bulimia nervosa can lead to various health complications, it is not directly associated with the development of diabetes mellitus.
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.