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.

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 D

Explanation

A. Autonomic dysreflexia: This condition typically occurs in individuals with spinal cord injuries above the T6 level and presents with sudden, severe hypertension, bradycardia, headache, and profuse sweating. It is not typically associated with alcohol withdrawal symptoms such as visual hallucinations and impaired consciousness.

B. Synergistic effect: This term refers to the combined effect of two or more substances or factors being greater than the sum of their individual effects. While alcohol withdrawal can interact with other substances or conditions to produce various effects, it is not a specific condition causing visual hallucinations and impaired consciousness.

C. Sleep deprivation: Prolonged sleep deprivation can lead to cognitive impairment, mood disturbances, and hallucinations, but it is not typically associated with impaired consciousness as described in the scenario. Additionally, the manifestations described are more indicative of alcohol withdrawal rather than sleep deprivation alone.

D. Delirium: Delirium is a state of acute confusion and altered consciousness characterized by disturbances in attention, awareness, cognition, and perception. Visual hallucinations and impaired consciousness are common features of delirium, especially in the context of alcohol withdrawal. Delirium often occurs due to underlying medical conditions, substance withdrawal, or medication side effects.

A. Remain 15 cm (6 in) away from the client B. Use a raised voice when speaking to the chem C. Determine the cause of the client's feelings D. Ask the client short close-ended question

Correct Answer is C

Explanation

A. Remain 15 cm (6 in) away from the client: Maintaining a safe physical distance is important to ensure the safety of both the client and the staff member. However, the specific distance may vary depending on the situation and the client's level of agitation. It's essential to maintain a safe distance while still engaging with the client in a supportive manner.

B. Use a raised voice when speaking to the client: Using a raised voice can escalate the situation further and may increase the client's agitation or aggression. It's important to speak calmly and softly to avoid escalating the situation.

C. Determine the cause of the client's feelings: Understanding the underlying reasons for the client's aggression can help the nurse address the root cause and implement appropriate interventions. It's important to listen actively to the client, validate their feelings, and demonstrate empathy.

D. Ask the client short close-ended questions: Close-ended questions typically elicit simple "yes" or "no" responses and may not encourage open communication or help the client express their feelings. Instead, it's more beneficial to ask open-ended questions that allow the client to express themselves and feel heard.

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 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 caring for a client who is experiencing visual hallucinations followed by impaired consciousness as a result of alcohol withdraw which of the following conditions should the nurse identify as causing these manifestations?

Correct Answer is D

Explanation

A nurse is using de-escalation techniques with a client who has become verbally aggressive with a staff member. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving haloperidol 2 mg IM every 6 hr. Available is haloperidol 5 mg/mL. How many mu should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a client who has just learned that her partner has died by suicide. Which of the following actions should the nurse take first

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

A charge nurse is planning an in-service for newly licensed nurses on tort law in mental health care. Which of the following scenarios should the charge nurse provide as an example of an unintentional tort?

A nurse in an urgent-care clinic is caring for a school-age child who has several visible bruises. The child's parent states. "My partner got fret today and came home angry. I don't think this will happen again" Which of the following responses should the nurse make?

A nurse is admitting a client who has posttraumatic stress disorder (PTSD) to a community mental health facility. Which of the following manifestations should the nurse expect when completing the admission assessment?

A nurse is caring for a client who reports a history of frequent alcohol consumption. Which of the following questions should the nurse ask when screening for alcohol use disorder?

A nurse on a mental health unit is planning a group therapy session about assertiveness training. For which of the following clients should the nurse recommend the training?