A client who is agitated is gesturing at the television in the day room and talking to an empty chair. Which interventions should practical nurse (PN) implement? Select all that apply.
Instruct the client to stop scaring the other clients.
Offer support and reassure the client being in a safe place.
Instruct team members to ignore the client's hallucinations.
Acknowledge that the client's perception is not real to others.
Restrict the client to his room and apply soft wrist restraints.
Use simple commands in a calm, soothing voice.
Correct Answer : B,D,F
A. Instruct the client to stop scaring the other clients: Telling the client to stop the behavior may increase agitation and mistrust. Clients experiencing hallucinations are responding to stimuli they believe are real, so confrontation should be avoided.
B. Offer support and reassure the client being in a safe place: Providing reassurance helps decrease anxiety and fear associated with hallucinations. Calm support conveys safety and establishes trust, which are essential in managing agitation.
C. Instruct team members to ignore the client's hallucinations: Ignoring the client’s experience can worsen distress and feelings of isolation. Staff should respond therapeutically by acknowledging the client’s emotions without reinforcing the hallucination.
D. Acknowledge that the client's perception is not real to others: This approach validates the client’s feelings while gently orienting them to reality. It helps maintain rapport and avoids reinforcing false perceptions, which supports reality testing.
E. Restrict the client to his room and apply soft wrist restraints: Restraints and isolation are unnecessary unless the client poses an immediate danger to self or others. Such measures could escalate agitation and violate ethical standards of care.
F. Use simple commands in a calm, soothing voice: Clear, calm communication helps the client process information more easily. It reduces overstimulation and conveys reassurance, aiding in the de-escalation of agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Auscultate all lung fields: In left-sided heart failure, fluid backs up into the lungs, leading to pulmonary congestion and crackles. Assessing all lung fields allows the PN to detect early signs of worsening HF, such as pulmonary edema, which can rapidly become life-threatening.
B. Measure urinary output: Monitoring urine output is important for assessing kidney perfusion and fluid balance, but pulmonary congestion poses a more immediate risk in left-sided HF than changes in urine output.
C. Inspect for sacral edema: Sacral edema is more commonly associated with right-sided heart failure. While peripheral edema should be monitored, it is less critical than evaluating for pulmonary complications in left-sided HF.
D. Check mental acuity: Altered mental status can occur if hypoxia develops from severe pulmonary congestion, but initial assessment focuses on lung function to prevent acute respiratory compromise.
Correct Answer is D
Explanation
A. Check the pedal pulse in the affected leg: Assessing circulation is important when vascular compromise is suspected, but a leg cramp during labor is typically due to muscle spasm, not circulatory problems. The priority is relieving discomfort through positioning.
B. Massage the calf and foot: Massaging the calf is contraindicated until a circulatory issue, such as a deep vein thrombosis, is ruled out. Manipulating the area could dislodge a clot if one were present, posing a serious risk.
C. Elevate the leg above the heart: Elevating the leg may reduce swelling but will not relieve a muscle cramp caused by strain or poor positioning during labor. It does not directly address the muscle tension responsible for the pain.
D. Extend the leg and flex the foot: This action stretches the gastrocnemius muscle and relieves the spasm causing the cramp. It is the safest and most effective immediate intervention for muscle cramps in laboring clients.
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