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:
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.

A. The nurse will call the client weekly to monitor the client's blood pressure and symptoms. B. The nurse will encourage the client to walk thirty minutes every day. C. The client will take up to 4 nitroglycerine tablets sublingually for chest pain. D. The client will record episodes of angina and self-management for one week.

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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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 is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?

Correct Answer is C

Explanation

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?

Correct Answer is D

Explanation

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