A nurse is caring for a client who has become violent and is threatening self-harm following a crisis. After ensuring enough staff are available, which of the following actions should the nurse take first?

Administer a sedative medication.

Perform a debriefing with the staff.

Acknowledge the client's emotions.

Place the client in restraints.

Answer and Explanation

The Correct Answer is C

A reason: Administer a sedative medication. While administering a sedative may be necessary to calm the client, it is not the first step. The nurse should initially attempt to de-escalate the situation using non-pharmacological interventions.

B reason: Perform a debriefing with the staff. Debriefing with the staff is important after the situation is under control, but it is not the immediate priority. The focus should first be on addressing the client's behavior and emotions.

C reason: Acknowledge the client's emotions. Acknowledge the client's emotions to de-escalate the situation and help the client feel heard and understood. This can reduce the immediate risk of violence or self-harm.

D reason: Place the client in restraints. Restraints should be used as a last resort when other interventions have failed and there is an immediate risk of harm. The nurse should first try to calm the client through verbal and emotional support.

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Correct Answer is C

Explanation

A reason: Encourage the client to attend group therapy sessions. While group therapy can be beneficial for some clients, it may not be the best initial approach for those with panic disorder. Group settings can sometimes increase anxiety and trigger panic attacks.

B reason: Allow the client to choose scheduled daily activities. While allowing clients some control over their daily activities can be empowering, it does not directly address the symptoms of panic disorder. Structured interventions and therapeutic techniques are more effective.

C reason: Use simple words to describe procedures to the client. Using simple, clear language when explaining procedures helps reduce anxiety and prevent misunderstandings that could trigger a panic attack. This approach is particularly effective for clients with panic disorder, who may become easily overwhelmed.

D reason: Avoid discussing topics that can trigger a panic attack. While it is important to be mindful of topics that may cause distress, complete avoidance can prevent clients from learning to manage their triggers. Therapeutic approaches often involve gradual exposure to triggers in a controlled and supportive environment.

A. The child has a history of jaw fractures. B. The child seems frightened of their parent. C. The child has had no immunization since birth. D. The child rocks back and forth continually.

Correct Answer is C

Explanation

A reason: The child has a history of jaw fractures. While a history of fractures may indicate physical abuse, it is not specifically indicative of neglect. Child neglect often involves failure to provide necessary care, not necessarily causing physical injury.

B reason: The child seems frightened of their parent. Fear of a parent can be a sign of abuse or neglect, but it alone is not a definitive indicator of neglect. It requires further investigation to determine the cause of the child's fear.

C reason: The child has had no immunizations since birth. Failure to provide necessary medical care, such as immunizations, is a clear indicator of neglect. It shows a lack of attention to the child's health and well-being.

D reason: The child rocks back and forth continually. Repetitive behaviors like rocking can be a sign of psychological distress or developmental issues but are not specific indicators of neglect. They require further evaluation to understand the underlying cause.

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A nurse is caring for a client who has become violent and is threatening self-harm following a crisis. After ensuring enough staff are available, which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is creating a plan of care for a client who has panic disorder. Which of the following interventions should the nurse include?

Correct Answer is C

Explanation

A nurse is conducting a child maltreatment screening of a family who has a toddler. Which of the following findings should the nurse identify as an indicator of possible child neglect?

Correct Answer is C

Explanation

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