A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?

Document the client's behavior every 15 min.

Obtain the provider's prescription within 60 min.

Monitor the client's vital signs every 4 hr.

Offer the client food and fluids every 2 hr.

Answer and Explanation

The Correct Answer is A

A.   Documenting the client's behavior every 15 minutes is essential for monitoring the client's condition, response to seclusion, and any changes in behavior or status.
B.   Obtaining the provider's prescription within 60 minutes may be necessary but does not address immediate nursing actions required after placing the client in seclusion.
C.   Monitoring vital signs every 4 hours is not specific to managing a client in seclusion and may not provide timely information about the client's condition or response to seclusion.
D.   Offering food and fluids every 2 hours is important for meeting the client's physiological needs but may not be appropriate immediately after placing the client in seclusion, depending on the circumstances and facility policies.

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Correct Answer is A

Explanation

A. Displacement involves redirecting emotions or behaviors from the original source to a less threatening or more accessible target. In this scenario, the client is redirecting his anger from his partner to the nurse, who is perceived as a safer target.
B. Compensation involves overachieving in one area to compensate for deficiencies in another area and is not demonstrated in this scenario.
C. Denial involves refusing to acknowledge the existence of a real situation or the feelings associated with it, which is not evident in the client's behavior.
D. Rationalization involves creating logical or socially acceptable explanations for behaviors or feelings that are unacceptable, which is not demonstrated in the client's behavior in this scenario.

A. "Take your medication with a meal to decrease the onset of dizziness." B. "Dizziness is a common adverse effect of the medication and is related to low blood pressure." C. "Dizziness typically indicates an allergic response, so the medication should be stopped immediately." D. "Take your medication first thing in the morning, and it will not cause as much dizziness."

Correct Answer is B

Explanation

A. Taking medication with a meal may help alleviate gastrointestinal side effects but is unlikely to affect dizziness caused by medication.
B. Quetiapine, an antipsychotic medication, commonly causes orthostatic hypotension, which can lead to dizziness. Explaining this to the client helps provide education about the medication's side effects.
C. Dizziness is not typically indicative of an allergic reaction to quetiapine. Advising the client to stop the medication immediately based solely on dizziness is not appropriate.
D. Taking the medication in the morning may or may not affect dizziness, as it depends on the individual's response to the medication. Additionally, orthostatic hypotension can occur at any time of day, not just in the morning.

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A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

Correct Answer is A

Explanation

A nurse is caring for a client who has been taking quetiapine for 1 week and reports dizziness. The client asks the nurse if the dizziness indicates an allergic reaction to the medication. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

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