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

Answer and Explanation

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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Correct Answer is D

Explanation

A. The statement "You can resume sexual activity 2 days after you complete your antiviral treatment" is incorrect. Chlamydia is a bacterial infection, and the standard treatment is with antibiotics, not antivirals. Additionally, the client should wait until they have completed the full course of antibiotics and have been re-evaluated by their healthcare provider before resuming sexual activity to prevent the spread of the infection.

B. The statement "Your sexual partners can receive a chlamydia vaccine to protect against infection" is incorrect. As of my last knowledge update in January 2022, there is no chlamydia vaccine available. Chlamydia is typically treated with antibiotics, and preventing transmission involves safe sexual practices and partner notification.

C. The statement "Chlamydia is an incurable infection that causes a thick, curd-like discharge" is incorrect. Chlamydia is a curable bacterial infection, and it may or may not cause symptoms. It does not typically cause a thick, curd-like discharge; that description is more characteristic of a yeast infection.

D. The statement "The law requires a report of each case of chlamydia to the local health department" is correct. Chlamydia is a notifiable disease, meaning healthcare providers are legally required to report cases to the local health department. This reporting is essential for public health surveillance, tracking the prevalence of the infection, and implementing measures to control its spread.

A. Flush the tube with 5 mL of water. B. Test the pH of fluid aspirated from the tube. C. Inject air through the tubing and auscultate for gurgling sounds: D. Change the bag and tubing system every 12 hr

Correct Answer is B

Explanation

A. Flush the tube with 5 mL of water:

Explanation: Flushing the tube with water is a routine practice before and after administering medications or feedings to maintain tube patency. However, it is not the primary action to confirm tube placement.

B. Test the pH of fluid aspirated from the tube (Correct Answer):

Explanation: Testing the pH of aspirated fluid helps confirm that the tube is in the stomach. A pH between 1 and 5 is generally indicative of gastric placement.

C. Inject air through the tubing and auscultate for gurgling sounds:

Explanation: This method is an older practice and is not recommended as a reliable method for verifying tube placement. Testing the pH is a more accurate and preferred method.

D. Change the bag and tubing system every 12 hr:

Explanation: Changing the bag and tubing system every 12 hours is a routine practice to maintain the integrity of the enteral feeding system. However, it is not specifically related to the initial steps in verifying tube placement.

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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?

Nursing Test Bank

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Correct Answer is B

Explanation

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