A client who is manic threatens others on the unit. Which would be the initial nursing action in response to this behavior?

Set limits on aggressive and intimidating behaviors

Offer to hold a group about healthy coping skills

Administer the client’s PRN medications

Insist the client take a “time-out” in their room

Answer and Explanation

The Correct Answer is A

Choice A reason: Setting limits on aggressive behavior during mania ensures safety by addressing the immediate threat. Mania involves elevated mood and impulsivity, which can lead to harmful actions. Clear boundaries reduce escalation, protect others, and help de-escalate the client’s heightened state without immediate medication or isolation.

Choice B reason: Offering a group on coping skills is inappropriate during acute mania with threatening behavior, as the client’s impulsivity and agitation impair their ability to engage in group therapy. Safety and de-escalation are priorities before addressing long-term coping strategies.

Choice C reason: Administering PRN medications, such as antipsychotics or benzodiazepines, may help calm mania but is not the initial action. Setting limits addresses immediate safety concerns first, allowing for safer medication administration if needed, as medications take time to act.

Choice D reason: Insisting on a “time-out” may escalate agitation in a manic client, as isolation can increase feelings of persecution or agitation. This approach is less effective than setting clear, calm limits to de-escalate threatening behavior and ensure unit safety.

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Correct Answer is A

Explanation

Choice A reason: A ventricular pacemaker stimulates the ventricles, producing a spike on the ECG before each QRS complex, indicating proper pacing and capture. This ensures the ventricles contract in response to the pacemaker’s electrical impulse, maintaining adequate cardiac output in clients with conduction issues.

Choice B reason: Pacemaker spikes after each P wave suggest atrial pacing, not ventricular pacing. Ventricular pacemakers target ventricular contraction, so spikes should precede the QRS complex, not follow the P wave, making this an incorrect indicator of proper ventricular pacemaker function.

Choice C reason: Pacemaker spikes with each T wave are not indicative of proper ventricular pacemaker function. T waves represent ventricular repolarization, and pacing at this phase is ineffective and potentially dangerous, as it does not initiate ventricular contraction, ruling out this option.

Choice D reason: Pacemaker spikes after each QRS complex indicate failure to pace appropriately, as ventricular depolarization has already occurred. Proper ventricular pacing requires spikes before the QRS to initiate contraction, making this an incorrect sign of a functioning ventricular pacemaker.

A. The potential for dependence and tolerance B. It should be taken first thing in the morning with food C. The importance of discontinuing immediately if addiction is suspected D. Increased caffeine consumption will increase the effectiveness

Correct Answer is A

Explanation

Choice A reason: Benzodiazepines enhance GABA activity, leading to rapid anxiety relief but with a high risk of tolerance and dependence. Teaching about this risk is critical to ensure the client understands the need for medical supervision, potential withdrawal symptoms, and strategies to prevent misuse or long-term dependency.

Choice B reason: Taking benzodiazepines with food may reduce gastrointestinal upset, but the timing is not critical for efficacy. This instruction is less urgent than addressing dependence, as benzodiazepines are effective regardless of meal timing, and the primary concern is their addictive potential.

Choice C reason: Discontinuing benzodiazepines abruptly can cause severe withdrawal symptoms, including seizures, due to their effect on GABA receptors. This is dangerous advice, as gradual tapering under medical supervision is required, making this choice incorrect and less critical than teaching about dependence risks.

Choice D reason: Increased caffeine consumption can counteract benzodiazepine effects by stimulating the central nervous system, potentially worsening anxiety. This is incorrect advice, as it could reduce the medication’s efficacy and exacerbate symptoms, making it less relevant than educating about dependence and tolerance risks.

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A client who is manic threatens others on the unit. Which would be the initial nursing action in response to this behavior?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?

Correct Answer is A

Explanation

What should the nurse plan to teach as a priority for a client who is taking a benzodiazepine daily for anxiety?

Correct Answer is A

Explanation

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