A client experiencing mania is scheduled for a chest x-ray. Before taking the client to the radiology department the nurse should:
Cancel the appointment until the patient can go unescorted
Explain the procedure in simple terms
Give a thorough explanation of the procedure
Call security to be on standby for possible behavior problems
The Correct Answer is B
Choice A reason: Canceling the appointment delays necessary care and is not appropriate unless safety cannot be managed.
Choice B reason: Clients experiencing mania have short attention spans and difficulty processing complex information. Explaining the procedure in simple, clear terms is the most effective approach.
Choice C reason: A thorough explanation may overwhelm the client and increase agitation due to their inability to focus.
Choice D reason: Calling security preemptively is unnecessary unless there is a history of violence. It may escalate the situation and increase paranoia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: Asking if the client feels pressured to do things they do not want to do helps identify coercion or abuse. This is a direct way to assess safety and autonomy in the relationship.
Choice B reason: Fear of a previous partner can indicate ongoing threats, stalking, or unresolved trauma. This question helps assess risk of continued abuse even after the relationship has ended.
Choice C reason: Asking if the client feels safe in their relationship is a broad but essential screening question. It allows the client to express concerns about current safety and potential abuse.
Choice D reason: Asking about a caretaker threatening harm is more relevant to elder abuse or dependent care situations rather than intimate partner violence. While important in other contexts, it does not directly assess intimate partner safety.
Correct Answer is A
Explanation
Choice A reason: Asking if the client has a plan to commit suicide is the priority intervention. It directly assesses the level of risk and helps determine the immediacy of danger. Suicide risk assessment is essential in borderline personality disorder, where impulsivity and self-harm are common.
Choice B reason: Assuming manipulation dismisses the seriousness of suicidal ideation. Even if manipulation is suspected, all suicidal statements must be taken seriously to ensure safety.
Choice C reason: Allowing the client to rest does not address the risk of suicide. Safety assessment must occur before any other intervention.
Choice D reason: Notifying family may be supportive but is not the immediate priority. The nurse must first assess the client’s risk and ensure safety before involving others.
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