A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply)

Speak to the client in a loud voice

Stand directly in front of the client

Request that security guards restrain the client

Talk to the client using short, simple sentences

Identify the client’s stressors

Answer and Explanation

The Correct Answer is D

Choice A reason: Speaking loudly escalates tension in an agitated client, mimicking confrontation and potentially worsening yelling or pacing. De-escalation requires a calm, low tone to soothe, not provoke. This action contradicts mental health principles for managing agitation, increasing risk, so it’s not appropriate here.

Choice B reason: Standing directly in front risks invading personal space, heightening agitation in a yelling, pacing client, possibly triggering aggression. A side approach maintains safety and openness, per de-escalation guidelines. This position endangers the nurse and client, making it an incorrect choice.

Choice C reason: Requesting restraints assumes immediate danger without de-escalation attempts, violating least restrictive care. Yelling and pacing alone don’t justify physical control unless harm is imminent. This premature escalation skips verbal intervention, so it’s not suitable unless safety fails.

Choice D reason: Short, simple sentences calm the client by reducing cognitive overload during agitation, facilitating understanding amid yelling and pacing. This de-escalation technique, part of crisis management, promotes cooperation safely. It’s a primary, effective step, making it a correct action here.

Choice E reason: Identifying stressors uncovers agitation triggers (e.g., fear, pain), guiding tailored de-escalation for a yelling, pacing client. This insight informs interventions, reducing escalation risk in mental health settings. It’s a proactive, therapeutic step, correctly included in the nurse’s response.

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Correct Answer is A

Explanation

Choice A reason: Olanzapine, an antipsychotic, can cause metabolic side effects like hyperglycemia, leading to increased thirst, a diabetes symptom. In schizophrenia treatment, monitoring this is key due to long-term risk. This question targets a common, serious effect, making it the priority to ask.

Choice B reason: Unintentional weight loss isn’t typical with olanzapine, which often causes weight gain via appetite increase. Schizophrenia itself rarely causes this unless appetite drops. This question misses the drug’s profile, so it’s not the best to assess side effects.

Choice C reason: Ringing in the ears (tinnitus) isn’t a known olanzapine side effect; it’s linked to drugs like quinine, not antipsychotics. It’s irrelevant to schizophrenia treatment monitoring. This question lacks clinical basis for this medication, making it incorrect.

Choice D reason: Decreased taste isn’t a reported olanzapine effect; it may alter appetite, but not taste perception directly. Schizophrenia might affect senses indirectly, but this isn’t drug-related. This question doesn’t target a key side effect, so it’s not the priority.

A. Instruct the client to expect ringing in the ears B. Place the client in restraints for 1 hour C. Repeat the dose in 15 minutes if the client is still anxious D. Initiate fall precautions for the client

Correct Answer is D

Explanation

Choice A reason: Ringing in the ears (tinnitus) isn’t a common lorazepam side effect; sedation, confusion, or dizziness are. Instructing this misinforms the client, potentially causing undue worry. Post-IM administration focuses on monitoring actual effects, not unrelated symptoms. This action lacks relevance to lorazepam’s profile, so it’s incorrect.

Choice B reason: Restraints for 1 hour post-lorazepam assume behavioral control needs without evidence of aggression. This violates least restrictive care, risking harm or agitation in an anxious client. Lorazepam calms, not escalates, behavior, making restraints unnecessary and unethical unless danger emerges.

Choice C reason: Repeating lorazepam in 15 minutes risks oversedation, as 1 mg IM peaks in 60-90 minutes, needing time to assess efficacy. Protocol requires monitoring, not immediate redosing, absent severe symptoms. This premature action endangers respiratory safety, so it’s not appropriate.

Choice D reason: Lorazepam’s sedative effects (drowsiness, dizziness) increase fall risk post-IM injection, especially in anxiety where mobility may persist. Initiating precautions like bed alarms or assistance ensures safety, a priority after benzodiazepine use. This action aligns with standard care, making it the correct choice.

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A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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