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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:
Postponing the interview until the next day may not be necessary and could delay necessary assessment and care.
Choice B rationale:
Documenting the client's paranoid behavior is important but should be done after the nurse attempts to engage with the client.
Choice C rationale:
Attempting to ask the client simple questions is a non-threatening approach that allows the nurse to start the assessment and establish some rapport. It respects the client's need for space while initiating communication.
Choice D rationale:
Asking another nurse to talk with the client may be an option later if the client remains uncooperative, but the nurse should first attempt to engage with the client directly.

A. Assist the client to the bathroom B. Assess mental status regularly C. Provide oral care at least twice a day D. Screen for orthostatic hypotension E. Monitor calcium levels F. Have an opioid agonist at the bedside

Correct Answer is ["B","C","D"]

Explanation

Choice A rationale:
Clonazepam is not typically associated with a significant risk of causing urinary retention or frequent bathroom needs. There's no immediate need for bathroom assistance related to clonazepam use.

Choice B rationale:
Clonazepam is a medication that affects the central nervous system and can influence mental status. Regular assessment helps monitor for any changes or adverse effects.

Choice C rationale:
Clonazepam is administered orally, and it's important to ensure the client's oral health and comfort, especially since dry mouth can be a side effect.

Choice D rationale:
Clonazepam can cause drowsiness and potential changes in blood pressure, which could lead to orthostatic hypotension. Screening for this condition helps ensure the client's safety when changing positions.

Choice E rationale:
Clonazepam does not typically affect calcium levels. Monitoring calcium levels is not a standard nursing intervention when starting clonazepam.

Choice F rationale:
Clonazepam is not an opioid, and it does not require having an opioid agonist at the bedside. This intervention is not relevant to clonazepam use.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

Correct Answer is C

Explanation

Patient Data History and Physical Exhibits here What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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