When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?
Request backup from the staff.
Stand in the doorway.
Provide for personal space.
Encourage the client to sit down.
The Correct Answer is C
Choice A rationale:
Requesting backup from the staff may be necessary if the situation escalates further, but it is not the initial action to take. Providing for personal space and attempting to de-escalate the situation should come first.
Choice B rationale:
Standing in the doorway may not be the most effective approach because it doesn't actively address the client's agitation or attempt to de-escalate the situation.
Choice C rationale:
Providing personal space is an important initial intervention when dealing with an agitated client. This approach helps maintain safety for both the nurse and the client and can reduce the perception of threat or intrusion.
Choice D rationale:
Encouraging the client to sit down may be a helpful de-escalation technique, but it should come after providing for personal space to ensure safety and reduce tension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
This option includes various factors but does not directly align with the CAGE questions.
Choice B rationale:
While it mentions liver enzyme and gastrointestinal complaints, it does not specifically address the CAGE questions about efforts to cut down, annoyance with questions, guilt, or using alcohol as an "Eye-opener."
Choice C rationale:
The CAGE questionnaire is designed to assess for alcohol misuse or dependency. The responses in choice C ("Efforts to cut down," "annoyance with questions," "guilt," and "drinking as an 'Eye-opener'") are the key elements of the CAGE questionnaire that indicate potential issues with alcohol use. These responses should be explored further to assess the client's relationship with alcohol and the impact it may have on their life.
Choice D rationale:
This option mentions minimizing drinking and missing family events but does not cover all the key elements of the CAGE questionnaire.
Correct Answer is D
Explanation
Choice A rationale:
Weekly monitoring of blood pressure and symptoms is important but does not address the specific issue of chest pain on exertion.
Choice B rationale:
Encouraging daily walking is generally a good recommendation for overall health but does not address the immediate concern of chest pain.
Choice C rationale:
Taking up to 4 nitroglycerine tablets for chest pain may provide temporary relief, but this should be done under the guidance of a healthcare provider and is not a long-term outcome.
Choice D rationale:
Recording episodes of angina and self-management for one week is a specific and appropriate outcome to monitor the client's chest pain and response to interventions.
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