A male client who is agitated is gesturing at the television in the day room and talking to an empty chair. Which interventions should the practical nurse (PN) implement? Select all that apply.
Instruct team members to ignore the client's hallucinations.
Acknowledge that the client's perception is not real to others.
Instruct the client to stop scaring the other clients.
Offer support and reassure the client that he is in a safe place.
Use simple commands in a calm, soothing voice.
Restrict the client to his room and apply soft wrist restraints.
Correct Answer : B,D,E
A. Instruct team members to ignore the client's hallucinations: Incorrect; ignoring can increase anxiety; therapeutic acknowledgment is needed.
B. Acknowledge that the client's perception is not real to others: Validates feelings without reinforcing hallucinations, helps maintain reality orientation.
C. Instruct the client to stop scaring the other clients: Confrontational and non-therapeutic.
D. Offer support and reassure the client that he is in a safe place: Reduces anxiety and builds trust.
E. Use simple commands in a calm, soothing voice: Helps with comprehension and reduces agitation.
F. Restrict the client to his room and apply soft wrist restraints: Only used if there is immediate danger to self/others; not indicated here.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Give 4 oz (120 mL) of apple juice:
Diaphoresis, confusion, and “not feeling right” indicate hypoglycemia. Rapid-acting carbohydrates should be given immediately if the client can swallow.
B. Administer glucagon 0.5 mg IM:
Used if the client is unconscious or unable to swallow safely.
C. Assess temperature:
Does not address the immediate risk of hypoglycemia.
D. Evaluate deep tendon reflexes:
Not relevant to urgent management of suspected hypoglycemia.
Correct Answer is D
Explanation
A. Foreign body:
Not a contraindication for ketorolac use; removal is priority.
B. Chemical burn:
Requires irrigation and emergency care, not NSAID eye drops.
C. Radiation exposure:
May cause eye irritation but not a contraindication for ketorolac.
D. Corneal abrasion:
Ketorolac can delay healing of corneal abrasions; contraindicated.
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