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A client in the psychiatric unit's dayroom is becoming agitated, talking incessantly, and starting to yell and swear at the other clients.

Which action should the practical nurse (PN) implement first?

A.

Instruct an unlicensed assistive personnel (UAP) to stay with the client.

B.

Notify the client's healthcare provider

C.

Administer an as needed (PRN) medication for agitation

D.

Escort the client to a calm and quiet place.

Answer and Explanation

The Correct Answer is D

d. Escort the client to a calm and quiet place.

The PN should use a calm and firm approach to de-escalate the situation and remove the client from the stressful environment. This can help prevent further agitation and potential violence.

The other options are not correct because:

  1. Instructing a UAP to stay with the client may not be effective or safe, as the UAP may not have the skills or training to handle an agitated client.
  2. Notifying the client's healthcare provider is not a priority action, as it does not address the immediate safety of the client and others.
  3. Administering a PRN medication for agitation may be indicated, but it is not the first action. The PN should try non- pharmacological interventions first, unless there is an imminent risk of harm.


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Related Questions

Correct Answer is ["0.6"]

Explanation

Step 1: The medication is prescribed as 30 mg every 12 hours, which means it is given twice a day. So, the total daily dosage in mg is 30 mg × 2 = 60 mg.

Step 2: The medication is available in 30 mg per 0.3 mL. So, to find out how many mL correspond to 60 mg, we set up a proportion: (30 mg / 0.3 mL) = (60 mg / x mL). Solving for x gives x = (0.3 mL / 30 mg) × 60 mg = 0.6 mL.

Therefore, the practical nurse should administer 0.6 mL of the medication each day.

Correct Answer is A

Explanation

Observe how UAP obtains temperatures.

Choice A rationale:

The PN should first observe how the unlicensed assistive personnel (UAP) obtains temperatures using a tympanic thermometer. This step is essential to determine if there is an error in the technique or if the thermometer is malfunctioning. Correct technique and proper use of equipment are crucial to obtaining accurate and reliable temperature readings.

Choice B rationale:

While returning the thermometer for recalibration might be necessary if the thermometer is indeed faulty, it should not be the first action the PN takes. Observing the UAP's technique will help identify if the issue lies with the equipment or the individual's method.

Choice C rationale:

Demonstrating how to use the equipment might be helpful if the UAP is incorrectly using the thermometer. However, observing the UAP's technique first will help the PN identify if there is a need for retraining or recalibration.

Choice D rationale:

Showing the UAP how to chart temperatures is not the first priority when inconsistent readings are noted. Ensuring the accuracy of temperature measurements is essential for proper patient care and assessment.

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