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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale:
While completing a thorough room search to remove potential self-harming objects is important, it should follow the immediate need for monitoring and intervention.

Choice B rationale:
Providing time alone in the client's room may not be appropriate when the client is exhibiting signs of distress and increased risk.

Choice C rationale:
Closely monitoring the client and having staff intervene as needed (Choice C) is the most important intervention in this situation. Clients with a history of self-mutilation who display signs of increased tension and agitation may be at higher risk for engaging in self-harming behaviors. Close observation and intervention can help prevent self-harm and ensure the client's safety.

Choice D rationale:
Giving firm, consistent expectations is important in the overall care plan but may not be effective in acute situations where immediate monitoring and intervention are required.

A. Muscle cramps B. Tingling sensation in her arms and legs C. Lightheadedness D. Fatigue E. 68-year-old with a history of diabetes, hypertension F. Blood Pressure: 146/82 mmHg G. Heart Rate: 114 bpm H. Temperature: 98.2 °F

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

Explanation

The assessment findings that require immediate follow-up by the nurse are: muscle cramps, tingling sensation in arms and legs, and lightheadedness.

These are signs of electrolyte imbalance, which can be caused by missed dialysis sessions, dehydration, or infection. Electrolyte imbalance can lead to serious complications such as cardiac arrhythmias, seizures, or coma.

The nurse should monitor the client's vital signs, neurological status, and cardiac rhythm, and notify the physician for further orders. The nurse should also assess the client's fluid status, hydration, and nutritional intake, and provide education on the importance of adhering to the dialysis schedule and dietary restrictions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Correct Answer is C

Explanation

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

Explanation

A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

The nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?

A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?

Patient Data Exhibits The client has been in IMU unit for 3 days and the physician plans to discharge her home today. Select the client actions that were effective in her treatment.

Patient Data Exhibits here The nurse is reviewing the physician's orders. Which of the following physician's orders requires priority attention from the nurse? Select all that apply.

Patient Data Exhibits The nurse determines the plan of care. For each action, click to indicate whether they would be included or not included in the plan of care for the client. Each row must have only one response option selected. Actions

The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?

Which intervention(s) should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)