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 B
Explanation
Choice A rationale:
Providing a supportive, structured environment for meals is an important aspect of the overall care plan for individuals with bulimia. However, it should not be the first intervention when a client is admitted with potential physical complications. Addressing the client's physical condition and safety is the initial priority.
Choice B rationale:
This is the correct initial intervention. Bulimia can lead to severe medical complications, including electrolyte imbalances, which can be life-threatening. Assessing the client's weight, vital signs, and electrolyte levels is crucial to determine the severity of physical issues and guide appropriate medical interventions.
Choice C rationale:
Discussing alternative strategies for binging and purging is an important aspect of treatment for bulimia, but it should follow the initial assessment of the client's physical condition. Addressing the client's medical needs takes precedence over discussing alternatives.
Choice D rationale:
While monitoring the client for possible vomiting is important in the care of individuals with bulimia, it should not be the first intervention when the client is admitted. Assessing the client's physical status and addressing potential medical complications should come before monitoring for specific behaviors.
Correct Answer is ["C","D","E","F","G"]
Explanation
Choice A rationale:
This is not a priority action for the nurse at this time. The nurse should first implement the ordered treatments for hyperkalemia and stabilize the client's condition before calling and giving a report to the receiving unit.
Choice B rationale:
Loop diuretics are medications that increase urine output and can lower potassium levels in mild cases of hyperkalemia. However, they are contraindicated in patients with ERSD who have oliguria or anuria (reduced or absent urine production). Loop diuretics can worsen renal function and fluid overload in these patients.
Choice C rationale:
Scheduling the client for hemodialysis is crucial, especially if the client has missed a scheduled dialysis session. Hemodialysis can help manage electrolyte imbalances and fluid overload.
Choice D rationale:
Checking the blood glucose level is important, especially in a client with a history of diabetes. Maintaining glycemic control is essential for overall health.
Choice E rationale:
Drawing a repeat potassium level is necessary to monitor the client's electrolyte status, especially given the ECG changes.
Choice F rationale:
Holding Lisinopril, an ACE inhibitor, is appropriate in this context, considering the client's elevated blood pressure and potential renal issues. It should be done under the guidance of the healthcare provider.
Choice G rationale:
Administering insulin, dextrose, and calcium gluconate can help manage hyperkalemia, which may be indicated by the ECG changes. Repeating the 12-lead EKG is important to assess the response to treatment and any changes in cardiac rhythm.
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