A nurse in an acute care mental health facility is sitting with a group of clients in a meeting room. A client suddenly jumps up and begins yelling angrily. Which of the following actions should the nurse take to ensure environmental safety?
Give the client more than one choice for resolving the conflict.
Move toward the client using an aggressive stance.
Choose two staff members to represent the staff and speak to the client.
Stand between the client and the doorway of the room.
The Correct Answer is D
A. Give the client more than one choice for resolving the conflict. While providing choices can be beneficial in some situations, it is not a direct action to ensure immediate environmental safety when a client is escalating aggressively.
B. Move toward the client using an aggressive stance. This approach is inappropriate and can escalate the situation further. A calm and non-threatening demeanor is essential in managing an aggressive client.
C. Choose two staff members to represent the staff and speak to the client. Having multiple staff members engage with an agitated client can sometimes help, but it’s crucial that any interaction is done calmly and without escalating the situation.
D. Stand between the client and the doorway of the room. This is the most appropriate action to ensure safety. Positioning yourself between the client and the exit can prevent the client from leaving the room and potentially harming themselves or others while ensuring a safe space to de-escalate.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Use moist heating pads on your joints." Moist heat can help relieve pain and stiffness in joints affected by osteoarthritis. It promotes blood flow and relaxation of muscles around the joint.
B. "Place a large pillow under your head." While proper head support is important for comfort, a large pillow might not be the best option as it can cause neck strain and is not specifically related to managing osteoarthritis pain.
C. "Do not perform muscle strengthening exercises." Muscle strengthening exercises are actually recommended for managing osteoarthritis as they help support and stabilize joints, reducing pain and improving function.
D. "Position a heavy bag of ice over your joints." While cold therapy can be useful for acute pain or inflammation, a heavy bag of ice can cause discomfort and potential tissue damage. Cold packs or ice bags used for short periods are more appropriate.
Correct Answer is D
Explanation
A. Instruct the client to take a sitz bath three times a week. While sitz baths may provide symptom relief, they are not a primary intervention for treating a UTI.
B. Request a prescription for gabapentin. Gabapentin is used for neuropathic pain, not for treating UTIs.
C. Encourage the client to drink 2 oz of grapefruit juice each day. Grapefruit juice is not recommended for UTIs; cranberry juice is often suggested instead.
D. Increase the client's fluid intake to 3 L each day. Increasing fluid intake helps flush bacteria from the urinary tract and is a key intervention in managing UTIs.
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