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 B
Explanation
Administering a large volume of medication in a single injection is not recommended for infants as it can lead to discomfort, tissue trauma, and potential complications such as muscle fibrosis or nerve injury. Dividing the medication into two injections with volumes under 1 mL is a common practice for infants and can help minimize discomfort and complications.
In addition, the nurse should select an appropriate needle size and injection site based on the infant's size and age. A 22 gauge 1 1/2 inch (3.8 cm) needle is too large for an infant and may cause discomfort and tissue damage. The nurse should use a smaller gauge needle and choose an appropriate injection site, such as the vastus lateralis muscle in the thigh or the dorsogluteal muscle in the buttocks, based on the infant's age and size.
Finally, administering an injection into the deltoid muscle is not recommended for infants as this muscle is not fully developed until later in childhood. Using a quick dart-like motion to inject into the dorsogluteal site is also not recommended as it can cause tissue damage and discomfort. Instead, the nurse should use a slow, steady technique to administer the injection while ensuring the infant is held securely by the parent or another caregiver.
Correct Answer is A
Explanation
The information that the nurse should obtain from the client first is: Reason for taking the aspirin.
It is important to first understand why the client was taking aspirin in order to determine the potential implications of switching to ibuprofen. Aspirin and ibuprofen are both nonsteroidal anti-inflammatory drugs (NSAIDs), but they have different indications and effects. Aspirin is commonly used for its antiplatelet properties to reduce the risk of heart attacks and strokes, while ibuprofen is primarily used for its analgesic and anti-inflammatory properties.
By understanding the reason for taking aspirin, the nurse can assess if the client was using it for its antiplatelet effects, which is important information to consider for the client's overall health and well-being.
Once the reason for taking aspirin is determined, the nurse can proceed to inquire about the other relevant information, such as the dosage of ibuprofen taken, presence of gastric pain, and amount of pain control. These details will help in assessing the client's current medication regimen, potential side effects or complications, and overall pain management.
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