A nurse is assisting in the care of a client in a mental health facility. During group therapy, the client stands up and starts pacing with their fists clenched. Which of the following actions should the nurse take first?
Administer haloperidol via the intramuscular route.
Collect data regarding the client's feelings.
Obtain assistance to apply wrist restraints.
Move the client into the seclusion room.
The Correct Answer is B
Rationale:
A. Administer haloperidol via the intramuscular route: Medication may be necessary for agitation, but administering it before assessing the client’s emotional state and safety is premature and could escalate distress.
B. Collect data regarding the client’s feelings: Assessing the client’s emotional state and reasons for pacing and clenched fists helps identify triggers, enabling the nurse to choose the least restrictive intervention and promote de-escalation.
C. Obtain assistance to apply wrist restraints: Restraints are a last resort to ensure safety and should only be used after less restrictive interventions have failed and when the client poses an immediate risk to self or others.
D. Move the client into the seclusion room: Seclusion is also a restrictive intervention requiring assessment of necessity. Moving the client without first gathering data and attempting de-escalation may violate client rights and worsen agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Polyuria: Polyuria is not a typical symptom of alcohol withdrawal. Although chronic alcohol use may affect renal function, withdrawal is more commonly associated with symptoms of autonomic hyperactivity rather than increased urine output.
B. Hypertension: Hypertension is a common manifestation of alcohol withdrawal due to autonomic nervous system overactivity. As the central nervous system adapts to the absence of alcohol, clients may experience elevated blood pressure, tremors, and agitation.
C. Constipation: Constipation is not expected during alcohol withdrawal. Clients are more likely to experience diarrhea or gastrointestinal upset due to nervous system stimulation and stress responses.
D. Bradycardia: Bradycardia is not characteristic of alcohol withdrawal. Instead, clients often present with tachycardia and other signs of heightened sympathetic activity due to the sudden absence of CNS depressant effects.
Correct Answer is C
Explanation
Rationale:
A. Oxytocin: Oxytocin is a uterotonic agent used to stimulate or augment labor, not to stop it. In the case of preterm labor at 36 weeks, administering oxytocin would worsen the situation by increasing uterine contractions and promoting delivery, which is not the intended goal.
B. Misoprostol: Misoprostol is typically used to induce labor by softening the cervix and stimulating contractions. It is contraindicated in clients experiencing preterm labor, as it would enhance uterine activity and could lead to premature delivery.
C. Magnesium sulfate: Magnesium sulfate is used in preterm labor to provide neuroprotection to the fetus and may also help reduce uterine contractions. It is especially indicated when labor is expected before 32–34 weeks but may still be prescribed at 36 weeks depending on clinical judgment.
D. Indomethacin: Indomethacin is a tocolytic agent used to suppress preterm labor contractions, but it is generally used before 32 weeks due to the risk of premature closure of the ductus arteriosus. At 36 weeks, the risks may outweigh the benefits, so it is not the first-line option at this gestational age.
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