The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement?
Use firmness and direct the client to sit for awhile.
Suggest to the client that he take a walk.
Move the client to a quiet place on the unit.
Encourage the client to use the punching bag
The Correct Answer is C
Delusions and loss of control can be distressing for the client and potentially disruptive to the unit environment. Moving the client to a quiet place helps create a calm and less stimulating environment, which can help reduce agitation and promote a sense of safety and security.
Using firmness and directing the client to sit for a while may escalate the situation and increase the client's distress. It is important to approach the client with empathy and provide a supportive environment rather than exerting control through firmness.
Suggesting the client take a walk or encouraging the client to use a punching bag may not be appropriate if the client is already displaying signs of agitation and losing control. These interventions may not address the underlying causes of the delusions and could potentially worsen the situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A low serum creatinine level indicates decreased muscle mass or impaired kidney function. However, it does not necessarily indicate that the 24-hour creatinine clearance test should be withheld or delayed.
Initiating the urine collection as prescribed allows for the accurate assessment of creatinine clearance and provides valuable information about the client's kidney function. The test results can help guide further evaluation and management of the client's condition.
Assessing the client's serum BUN level, notifying the healthcare provider of the results, or assessing for signs of hypokalemia may be relevant in certain situations but are not the immediate priority based on the information provided.
Correct Answer is A
Explanation
The client's history of lung cancer, persistent hoarseness, chronic cough, and labored respirations when speaking indicate potential respiratory complications. Coarse breath sounds may suggest the presence of airway obstruction or fluid accumulation in the lungs, which can be indicative of a worsening condition.
The nurse should intervene promptly by assessing the client's respiratory status further, providing appropriate respiratory support, and notifying the healthcare provider for further evaluation and intervention.
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