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.)

Identify the client's stressors.

Talk to the client using short, simple sentences.

Speak to the client in a loud voice.

Request that security guards restrain the client.

Stand directly in front of the client.

Answer and Explanation

Correct Answer : A,B

Choice A reason: Identifying the client's stressors is a crucial step in managing agitation. Understanding what triggers the client's distress can help the nurse to address the underlying issues and de-escalate the situation.

Choice B reason: Using short, simple sentences can help to communicate effectively with an agitated client. It ensures that the client can process the information without being overwhelmed, which is important for calming the situation.

Choice C reason: Speaking to the client in a loud voice is not recommended as it may escalate the situation. It's important to maintain a calm and soothing tone to avoid further agitation.

Choice D reason: Requesting that security guards restrain the client should be a last resort, only if the client poses an immediate threat to themselves or others. Less restrictive measures should be attempted first.

Choice E reason: Standing directly in front of an agitated client can be perceived as confrontational. It's better to maintain a non-threatening stance and ensure there is enough space to allow the client to feel safe.

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Correct Answer is C

Explanation

Choice A reason: Notifying law enforcement within 2 hours if the person cannot be found is important, but immediate action is usually recommended in such cases. The sooner the authorities are alerted, the better the chances of locating the individual safely.

Choice B reason: Giving the most recent photo to the police is a proactive step in case the person goes missing. It can help law enforcement quickly disseminate the information and aid in the search. However, this is a reactive measure rather than a preventive one.

Choice C reason: Placing a sliding bolt lock just above the doorknob can prevent the individual from wandering, which is a common and dangerous issue in people with advanced Alzheimer's disease. This measure helps ensure the person's safety by preventing unsupervised exits from the home.

Choice D reason: Ensuring the bedroom is dark while the person is sleeping may not be advisable. Adequate night lighting is important for preventing falls if the person needs to get up during the night. A completely dark room can increase the risk of injury.

A. "You should avoid stressful activities prior to going to sleep." B. "You should plan to exercise 2 hours before going to sleep." C. "You should take a 2-hour nap during the afternoon." D. "You should relax by watching a television show in bed before going to sleep."

Correct Answer is A

Explanation

Choice A reason: Engaging in stressful activities before bedtime can increase alertness and make it difficult to fall asleep. The nurse's recommendation to avoid stress before sleep is in line with good sleep hygiene practices that promote relaxation and readiness for sleep.

Choice B reason: Exercising too close to bedtime can be stimulating and may hinder the ability to fall asleep. It is generally recommended to finish exercising at least 3 hours before bedtime to allow the body to wind down.

Choice C reason: Taking long naps, especially in the afternoon, can disrupt nighttime sleep patterns. For individuals with insomnia, it is better to avoid naps or limit them to early in the day and for short durations.

Choice D reason: Watching television in bed can negatively impact sleep due to the light from the screen and the content, which can be stimulating. It is recommended to keep the bedroom environment conducive to sleep, which means no screens before bedtime.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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