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 C
Explanation
A. "Maybe you should wait to have the procedure."
This response may come across as directive and could potentially influence the client's decision. It does not encourage the client to express their feelings or concerns but suggests a specific course of action.
B. "This is a common feeling for clients to have before the procedure."
While it's true that many clients may experience conflicted feelings before undergoing certain procedures, this response is somewhat dismissive. It does not invite the client to explore their specific concerns and may not address the individual nature of the client's feelings.
C. Share more with me about your concerns related to the procedure.
This response encourages the client to express their concerns and provides an opportunity for the nurse to understand the specific issues causing the conflict. It demonstrates empathy and openness, fostering a therapeutic nurse-client relationship. By inviting the client to share more, the nurse can gain insight into the client's emotional and psychological concerns about the tubal ligation.
D. "Why are you concerned about the procedure?"
While this question is an attempt to understand the client's concerns, it may be perceived as too direct or confrontational. The wording might make the client feel defensive or pressured to justify their feelings. The more open-ended phrasing in option C is generally more conducive to therapeutic communication.
Correct Answer is B
Explanation
A.While it is important to have nonperishable food items, they should generally be checked and rotated every 6 months to a year to ensure they remain within expiration dates and to maintain freshness. Depending on storage conditions, some items may degrade sooner, so this timeframe may be insufficient.
B.In a disaster situation, access to pharmacies may be limited, so having a backup supply of essential nonprescription medications like pain relievers, antacids, and allergy medications is essential. This ensures that individuals have what they need to manage minor health issues without needing immediate access to stores.
C.Current recommendations typically advise having enough supplies for at least 3 days (72 hours) to a week, as this is generally the period required before external help may arrive during a disaster. While gathering supplies for two weeks can be helpful, it may not be feasible for everyone due to storage limitations.
D.The recommended amount of water for emergency situations is 1 gallon (approximately 3.8 liters) per person per day, which accounts for drinking and basic hygiene needs. Two liters would not be sufficient for most people’s daily water needs during an emergency.
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