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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While reporting the fire details to the facility emergency extension is important, the immediate action to ensure the safety of everyone in the facility is to activate the fire alarm. Activating the fire alarm alerts the entire facility to the presence of a fire and initiates the appropriate emergency response.
B. Closing the door to the client's room is a secondary action and can be done after activating the fire alarm. However, the priority is to activate the fire alarm to quickly notify others about the potential danger.
C. Activating the fire alarm is the immediate action to take in the event of a fire. This step ensures that the fire response team is alerted, and appropriate emergency measures are initiated promptly.
D. Turning off electrical equipment can be a safety measure, but it is not the first priority when there is an active fire. Activating the fire alarm and ensuring the evacuation of individuals from the area take precedence.
Correct Answer is D
Explanation
A. Medication administration record:
The medication administration record (MAR) primarily contains information related to medications, dosages, and administration times. While it provides important details about medications, it may not offer a comprehensive overview of the client's overall care.
B. Standardized care plan:
A standardized care plan typically outlines general care guidelines and interventions for specific conditions. It may provide a structured approach to care but might lack the individualized details needed for a specific client.
C. 180 record:
The term "180 record" does not commonly refer to a standard nursing documentation form. It might be a local or facility-specific term. Without additional information, it's unclear what type of information this form would contain.
D. Client care Kardex:
This is the correct answer. The Client care Kardex, also known as the patient care summary or Kardex, is a document that consolidates key information about a client's care, including diagnoses, treatments, procedures, and other relevant details. It provides a snapshot of the client's current status and facilitates communication among healthcare providers.
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