A nurse is caring for a client in an inpatient psychiatry unit
Drag words from the choices below to fill in each blank in the following sentence.
Which of the following actions should the nurse take first
The nurse should
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}
C) Offer the client a physical outlet
Encouraging the client to engage in a physical activity, such as walking or using a stress ball, helps release pent-up energy in a non-threatening way. This approach aligns with de-escalation techniques, which should be attempted before pharmacologic or restrictive interventions.
D) Offer the client medication
If the client's agitation continues despite non-pharmacologic interventions, offering as-needed medication (such as an anxiolytic or antipsychotic) may help manage escalating aggression. Medication should be a secondary measure after attempting verbal de-escalation and physical outlets.
A) Place the client in restraints
Restraints are a last resort and should only be used if the client poses an immediate danger to themselves or others after all other de-escalation strategies have failed.
B) Grab the client’s hand
Physically intervening without the client’s consent can increase aggression and pose a safety risk for both the client and the nurse. Maintaining a safe distance is a better approach.
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Related Questions
Correct Answer is C
Explanation
A) If I have a severe headache coupled with confusion, I’ll try and take a nap: Severe headache and confusion can be signs of serious side effects of risperidone, such as neuroleptic malignant syndrome (NMS) or other severe reactions. Simply trying to rest without contacting the healthcare provider could delay necessary intervention. Immediate medical attention is recommended for these symptoms.
B) If I promptly stop the medication if I have difficulty sleeping: Discontinuing risperidone without consulting a healthcare provider could lead to withdrawal effects or worsen symptoms. Difficulty sleeping can be a side effect of the medication, but the client should discuss any concerns with the healthcare provider before stopping the medication.
C) If I’m feeling a little dizzy in the morning, I’ll be sure to get out of bed slowly: Dizziness, particularly in the morning, is a common side effect of risperidone due to its potential to cause orthostatic hypotension (a drop in blood pressure when standing up). The client’s statement demonstrates understanding of how to manage dizziness safely by changing positions slowly to prevent falls or injury.
D) I’ll call my doctor immediately with any early signs of congestion: While it is important to report any signs of infection or congestion, it is not directly related to risperidone use. Respiratory symptoms are not common early side effects of this medication, and while reporting them is always wise, this specific instruction is not the most directly relevant to risperidone's known side effects.
Correct Answer is ["1.3"]
Explanation
1. Convert the toddler's weight from pounds to kilograms:
1 lb = 0.454 kg
Weight in kg = 22 lb X 0.454 kg/lb = 9.988 kg (approximately 10 kg)
Calculate the total daily dose of furosemide:
Daily dose = 2 mg/kg X 10 kg = 20 mg
Calculate the dose per administration:
The daily dose is divided into equal doses every 8 hours. Since there are 24 hours in a day, this means 24 hours / 8 hours = 3 doses per day.
Dose per administration = 20 mg / 3 doses = 6.666... mg (approximately 6.67 mg)
Determine the concentration of the furosemide injection:
The available furosemide injection is 5 mg/mL.
Calculate the volume (in mL) to administer per dose:
Use the concentration as a conversion factor:
Volume (mL) = Dose per administration (mg) / Concentration (mg/mL) Volume (mL) = 6.67 mg / 5 mg/mL = 1.334 mL
Round to the nearest tenth:
1.3 mL.
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