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 D
Explanation
A. The child will no longer be contagious, no need to take any further precautions:
RSV remains contagious for days to weeks after symptoms begin.
B. Make sure there are no children under the age of 6 months around the infected child:
Although infants are more vulnerable, all children are at risk - restriction should apply to everyone.
C. The child can be around other children but should wear a mask at all times:
Masks are not fully effective in preventing RSV spread, especially in very young children.
D. Do not expose other children as the virus is very contagious even without direct oral contact:
RSV spreads through respiratory droplets and contaminated surfaces.
Correct Answer is B
Explanation
A. Incentive spirometry is uncomfortable but necessary for your postoperative care:
This statement is negative and does not explain the purpose, which may discourage use.
B. Deep breathing exercises using the spirometer will help prevent postoperative complications:
Positive explanation that reinforces the importance of lung expansion and prevention of atelectasis or pneumonia.
C. Failure to keep your lungs working may result in pneumonia and death:
While partially true, this statement is fear-based and not therapeutic.
D. You will use the spirometer for the first postoperative day only:
Incentive spirometry is used for several days post-op until mobility and breathing patterns normalize.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
