A nurse is caring for a client who has a history of aggression and is threatening to harm the staff on the unit.
Which of the following actions should the nurse take first?

Place the client in seclusion.

Use verbal de-escalation techniques to calm the client.

Offer the client a medication to help them calm down.

Arrange for a critical incident debriefing with the staff.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Placing a client in seclusion involves isolating them in a safe area to prevent harm to themselves or others. While seclusion may be necessary if de-escalation fails and the client poses an immediate threat, it should not be the first action. Less restrictive interventions should be attempted first to address the client's agitation and potential aggression.

Choice B rationale

Verbal de-escalation techniques are the initial and least restrictive interventions for managing a client who is threatening harm. These techniques involve using calm communication, active listening, empathy, and setting clear limits to help the client regain control and reduce their agitation without resorting to more restrictive measures.

Choice C rationale

Offering medication to calm the client may be considered if verbal de-escalation is ineffective and the client's agitation escalates. However, it is not the first action. A thorough assessment of the client's condition and the reason for their agitation should precede medication administration, and it should be used in conjunction with other de-escalation strategies.

Choice D rationale

Arranging for a critical incident debriefing with the staff is an important step after a crisis situation has been resolved to review the event, support staff, and identify areas for improvement. However, it is not the immediate action to take when a client is actively threatening harm to staff. The immediate priority is to ensure the safety of the client and staff.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["A","B","D","E"]

Explanation

Choice A rationale

Tooth erosion occurs in clients with anorexia nervosa due to the frequent vomiting associated with bulimic behaviors, which can be present in some individuals with anorexia. Gastric acid erodes tooth enamel over time, leading to sensitivity, discoloration, and decay. This is a direct physiological consequence of repeated exposure to stomach acid.

Choice B rationale

Hypotension, or low blood pressure, is a common finding in anorexia nervosa. Reduced food intake leads to decreased body mass and lowered metabolic rate. This can result in decreased cardiac output and peripheral vasodilation, causing systolic blood pressure below the normal range of 90-120 mmHg and diastolic blood pressure below 60-80 mmHg.

Choice C rationale

Diarrhea is not a typical finding in anorexia nervosa. Constipation is more common due to decreased food intake and slowed gastrointestinal motility. While laxative abuse can cause diarrhea, it is not a primary expectation in anorexia nervosa itself.

Choice D rationale

Cold extremities are often present in clients with anorexia nervosa due to poor circulation and a decreased metabolic rate. The body conserves energy by reducing blood flow to the periphery, leading to cold hands and feet. This is a physiological adaptation to conserve core body temperature in the face of inadequate caloric intake.

Choice E rationale

Lanugo, a fine, downy hair, can develop on the face and body of individuals with anorexia nervosa. This is a physiological response to significant weight loss and decreased body fat, as the body attempts to conserve heat. It is similar to the hair seen on newborns and is a sign of the body trying to insulate itself.

A. Renew the restraint prescription every 48 hours. B. Attach the restraints to the side rail of the client's bed. C. Maintain 1 fingerbreadth between the restraint and the client's skin. D. Use a quick-release tie to restrain the client.

Correct Answer is D

Explanation

Choice A rationale

Restraint prescriptions for adults typically need to be renewed every 24 hours, according to most healthcare facility policies and regulatory guidelines, not every 48 hours. This frequent review ensures ongoing assessment of the client's need for restraints.

Choice B rationale

Attaching restraints to the side rail of the client's bed is dangerous because the side rail can move independently of the bed frame. This can cause injury to the client if they try to move or reposition themselves, potentially leading to strangulation or other harm. Restraints should be secured to a stable part of the bed frame.

Choice C rationale

Maintaining 2 fingerbreadths between the restraint and the client's skin is the standard to ensure proper circulation and prevent skin breakdown. One fingerbreadth would be too tight and could compromise blood flow and nerve function.

Choice D rationale

Using a quick-release tie is essential for safety when applying restraints. This allows for rapid removal of the restraints in case of an emergency, such as compromised circulation or the need for immediate medical intervention.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who has a history of aggression and is threatening to harm the staff on the unit.Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has anorexia nervosa.Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is caring for a client who is combative and requires wrist restraints.Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is collecting data from a female client who has bulimia nervosa.Which of the following manifestations should the nurse expect?

A nurse is contributing to the plan of care for a client who has borderline personality disorder.Which of the following interventions should the nurse recommend?

A nurse is caring for a male client who is to begin therapy with valproic acid.Which of the following diagnostic results should the nurse plan to review before administering the first dose?

A nurse is receiving report on four clients at the beginning of the shift.Which of the following clients should the nurse check first?

A nurse in a provider's office is collecting data from a client.Which of the following findings should the nurse identify as a risk factor for depression? (Select all that apply.)

A nurse is reinforcing teaching with a client who has bipolar disorder and has a new prescription for lithium.To address possible adverse effects, the nurse should include that which of the following laboratory values will be monitored while the client is taking this medication?

A nurse is assisting in the care of a 40-year-old female client on an inpatient mental health facility. Exhibits For each finding, click to specify if the finding indicates an unrelated condition, improvement of the condition, or worsening of the condition.

A nurse is beginning a therapeutic relationship with a client who has paranoid personality disorder. Which of the following strategies should the nurse plan to use?

A nurse is caring for a client who has a history of aggression and is threatening to harm the staff on the unit.
Which of the following actions should the nurse take first?