The nurse notices a client wandering in the hospital hall giggling, with bizarre behavior that is annoying and frightening other clients. A priority in caring for her is to:
Encourage social interaction.
Discuss the bizarre behavior.
Give the client information about her illness.
Provide a safe environment.
The Correct Answer is D
Choice A Reason:
Encouraging social interaction might not be appropriate in this situation. The client’s bizarre behavior is already causing distress to others, and encouraging more interaction could exacerbate the problem. The priority should be to address the immediate safety and well-being of both the client and others. Once the client is in a safe environment, social interaction can be encouraged in a controlled and therapeutic manner.
Choice B Reason:
Discussing the bizarre behavior with the client might not be effective in the moment, especially if the client is not in a state to understand or engage in such a discussion. The primary focus should be on ensuring safety and stability before addressing specific behaviors. Once the client is calm and in a safe environment, discussions about behavior can be more productive.
Choice C Reason:
Providing information about the client’s illness is important for long-term management and understanding, but it is not the immediate priority in this situation. The client’s current state requires immediate intervention to ensure safety. Education about the illness can be provided once the client is stabilized and in a better position to comprehend the information.
Choice D Reason:
Providing a safe environment is the most immediate and crucial priority. The client’s behavior is not only distressing to others but could also pose a risk to herself and others. Ensuring the client is in a safe, controlled environment helps to prevent harm and allows for further assessment and appropriate interventions. Safety is always the first priority in managing acute behavioral disturbances.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Lorazepam is a benzodiazepine commonly used to manage acute agitation and anxiety. It works by enhancing the effect of the neurotransmitter GABA, which has a calming effect on the brain. Lorazepam is often administered in emergency situations to quickly reduce agitation and prevent escalation to violence. Its rapid onset of action makes it an ideal choice for managing acute episodes of agitation and potential assault.
Choice B Reason:
Valproic acid is an anticonvulsant and mood stabilizer used primarily for the treatment of epilepsy and bipolar disorder. While it can help manage mood swings and prevent manic episodes, it is not typically used for the immediate management of acute agitation or aggression. Its effects are not rapid enough to address an escalating situation effectively.
Choice C Reason:
Bupropion is an atypical antidepressant used to treat major depressive disorder and to support smoking cessation. It works by inhibiting the reuptake of norepinephrine and dopamine, but it does not have the sedative properties needed to manage acute agitation or aggression. Therefore, it is not suitable for immediate intervention in a potentially violent situation.
Choice D Reason:
Sertraline is a selective serotonin reuptake inhibitor (SSRI) used to treat depression, anxiety disorders, and other mood disorders. While it is effective for long-term management of anxiety and depression, it does not have the rapid calming effects required for managing acute agitation or potential assault. SSRIs generally take several weeks to achieve their full therapeutic effect.
Correct Answer is ["C","E"]
Explanation
The correct answer is c, e.
Choice A Reason:
The statement “Clear and organized speech” is incorrect. Clients with delirium often exhibit disorganized thinking and speech. Their speech may be rambling, irrelevant, or incoherent, reflecting their fluctuating mental state. Clear and organized speech is more characteristic of a person without cognitive impairment or with stable cognitive function.
Choice B Reason:
The statement “Increased attention and focus” is incorrect. Delirium is characterized by a disturbance in attention and awareness. Clients with delirium typically have difficulty sustaining or shifting attention, which is a key diagnostic criterion. Increased attention and focus are not consistent with the presentation of delirium.
Choice C Reason:
The statement “Fluctuating levels of consciousness” is correct. One of the hallmark features of delirium is the fluctuation in the level of consciousness throughout the day3. Clients may experience periods of lucidity interspersed with confusion and disorientation. This fluctuation is a critical diagnostic indicator of delirium.
Choice D Reason:
The statement “Stable and consistent cognitive function” is incorrect. Delirium is marked by an acute change in cognitive function, which is neither stable nor consistent. Cognitive functions such as memory, orientation, and language are typically impaired and fluctuate over time. Stable cognitive function would not support a diagnosis of delirium.
Choice E Reason:
The statement “Agitation and aggression” is correct. Clients with delirium often exhibit behavioral disturbances, including agitation and aggression. These symptoms can result from the confusion and disorientation experienced during delirium. Recognizing these behavioral changes is important for the diagnosis and management of delirium.
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