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. Administer a sedative medication: While sedation may be necessary in some cases to manage acute agitation or aggression, it should not be the first action taken. Administration of sedative medication requires a careful assessment of the client's condition, potential drug interactions, and individualized dosing considerations. It's important to consider less restrictive interventions before resorting to sedation.

B. Perform a debriefing with the staff: Debriefing with the staff is an essential step in processing the crisis situation and ensuring the well-being of the team. However, it should not be the first action taken when the client is in immediate danger of harming themselves or others.

C. Acknowledge the client's emotions: Acknowledging the client's emotions and validating their feelings can help establish rapport and de-escalate the situation. However, if the client is actively threatening self-harm or violence, addressing safety concerns should take precedence.

D. Place the client in restraints: Restraints should only be used as a last resort and when less restrictive interventions have failed to ensure the safety of the client and others. Restraints should not be the first action taken, especially if there are other interventions that can be attempted to de-escalate the situation.

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Correct Answer is C

Explanation

a.Spending equal time with clients regardless of their insurance status: This situation relates more to justice, ensuring fairness and equality in client care, rather than fidelity.

b.This scenario represents the principle of veracity, which involves providing truthful and accurate information to clients. It ensures that clients are fully informed and can give informed consent regarding their treatment.

c.Respecting the decision of clients to refuse to participate in group therapy:Fidelityrefers to the duty to be loyal, faithful, and keep promises. It involves maintaining trust and being reliable in our interactions with clients. This situation aligns with fidelity. Respecting a client's decision to refuse treatment, even if it's something the nurse believes would be beneficial, demonstrates fidelity to the client's autonomy and their right to make choices about their care.

d.This situation reflects the principle of beneficence, which involves taking actions to benefit clients, including continuing education to improve client care and nonmaleficence (avoiding harm).

A. Orthostatic hypotension B. Diarrhea C. Hyperactivity D. increased urinary output

Correct Answer is A

Explanation

A. Orthostatic hypotension: Orthostatic hypotension, a sudden drop in blood pressure upon standing up, is a common adverse effect of tricyclic antidepressants. TCAs can block the alpha-1 adrenergic receptors, leading to decreased vascular tone and subsequent orthostatic hypotension.

B. Diarrhea: Diarrhea is not typically associated with tricyclic antidepressants. In fact, constipation is a more common gastrointestinal adverse effect of TCAs due to their anticholinergic properties, which can slow down bowel motility.

C. Hyperactivity: Hyperactivity is not a common adverse effect of tricyclic antidepressants. Instead, TCAs may cause sedation or drowsiness due to their antihistamine properties.

D. Increased urinary output: Tricyclic antidepressants can cause urinary retention rather than increased urinary output. Anticholinergic effects of TCAs can lead to urinary hesitancy, difficulty initiating urination, or retention, particularly in individuals with benign prostatic hyperplasia.

C. Hyperactivity: Hyperactivity is not a common adverse effect of tricyclic antidepressants. Instead, TCAs may cause sedation or drowsiness due to their antihistamine properties.

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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 charge nurse in a community mental health clinic is discussing ethical concepts of client care with a newly licensed nurse. The charge nurse should use which of the following situations as an example of fidelity?

Correct Answer is C

Explanation

A nurse is caring for a client who is taking a tricyclic antidepressant. For which of the following findings should the nurse monitor as an adverse effect of tricyclic antidepressants?

Correct Answer is A

Explanation

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