A nurse in a long-term care facility is monitoring clients in the day room. A client who has dementia becomes angry and starts screaming at the nurse. Which of the following interventions should the nurse take first?
Engage the client in a repetitive activity as a distraction.
Place the client in a seclusion room.
Apply wrist restraints to the client.
Administer PRN haloperidol IM to the client
The Correct Answer is A
A. Engage the client in a repetitive activity as a distraction:
This is the correct answer. Redirecting the client's focus to a repetitive and calming activity can help distract them from the source of agitation and potentially de-escalate the situation.
B. Place the client in a seclusion room:
Seclusion should only be used in situations where it is absolutely necessary for the safety of the client or others. Placing a client with dementia in seclusion is not the first choice and should be avoided if possible.
C. Apply wrist restraints to the client:
Restraints should be a last resort and used only when there is an imminent risk of harm to the client or others. Restraints can escalate agitation and should not be the initial response.
D. Administer PRN haloperidol IM to the client:
The use of medication should be considered later in the escalation process and after other non-pharmacological interventions have been attempted. It is not the first intervention, especially when there are non-pharmacological options available.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incentive spirometer:
An incentive spirometer is used to encourage deep breathing and prevent respiratory complications, but it is not specifically indicated for the management of sleep apnea.
B. Continuous positive airway pressure (CPAP) machine.
The description of the client stopping breathing for 30-second intervals while sleeping at night is suggestive of sleep apnea. A Continuous Positive Airway Pressure (CPAP) machine is commonly used for the management of sleep apnea. It delivers a continuous stream of air to keep the airway open, preventing pauses in breathing during sleep.
C. Yankauer suction equipment:
Yankauer suction equipment is used for oral suctioning and is not related to addressing the breathing pauses associated with sleep apnea.
D. Nebulizer:
A nebulizer is used to administer inhaled medications, typically for respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD). It is not the primary equipment for addressing the respiratory pauses seen in sleep apnea.
Correct Answer is A
Explanation
A. Engage the client in a repetitive activity as a distraction:
This is the correct answer. Redirecting the client's focus to a repetitive and calming activity can help distract them from the source of agitation and potentially de-escalate the situation.
B. Place the client in a seclusion room:
Seclusion should only be used in situations where it is absolutely necessary for the safety of the client or others. Placing a client with dementia in seclusion is not the first choice and should be avoided if possible.
C. Apply wrist restraints to the client:
Restraints should be a last resort and used only when there is an imminent risk of harm to the client or others. Restraints can escalate agitation and should not be the initial response.
D. Administer PRN haloperidol IM to the client:
The use of medication should be considered later in the escalation process and after other non-pharmacological interventions have been attempted. It is not the first intervention, especially when there are non-pharmacological options available.
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