A nurse is caring for a client who has dementia. The client is agitated and is having difficulty staying in his chair. Which of the following actions should the nurse take first?
Apply a vest restraint on the client.
Place the client in bed with the two side rails raised.
Place a seat alarm in the client's chair.
Administer lorazepam the client.
The Correct Answer is C
Choice A Rationale: Applying a vest restraint should not be the first action and should only be considered as a last resort after other alternatives have been explored.
Choice B Rationale: Placing the client in bed with two side rails raised may restrict the client's mobility and is not the first choice for managing agitation.
Choice C Rationale: Placing a seat alarm in the client's chair is the first action to take because it allows the nurse to monitor the client's movements and respond promptly to any attempts to get out of the chair while ensuring safety.
Choice D Rationale: Administering lorazepam should not be the first action and should only be considered after non-pharmacological interventions have been attempted
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Rationale: Linking the pain to nasal stuffiness is not an accurate explanation of trigeminal neuralgia.
Choice B Rationale: Hypoglycemia is not typically related to trigeminal neuralgia.
Choice C Rationale: Releasing catecholamines with infection or stress is not the primary cause of trigeminal neuralgia.
Choice D Rationale: Pain is often due to stimulation of the affected nerve by pressure and temperature. This is a more accurate and relevant explanation for trigeminal neuralgia.
Correct Answer is ["B","E"]
Explanation
Choice A Rationale: Tetanus does not affect only the spinal cord; it is a systemic bacterial infection that affects the nervous system and muscles.
Choice B Rationale: Manifestations of tetanus can include sustained muscle contractions, which result in muscle stiffness and spasms.
Choice C Rationale: Tetanus is not caused by a recent viral infection; it is caused by the bacterium Clostridium tetani.
Choice D Rationale: While tetanus can result from contaminated wounds, it is not typically associated with improperly processed foods. It is caused by the spores of the Clostridium tetani bacterium.
Choice E Rationale: Tetanus spores are commonly found in soil, gardens, and manure. Contaminated wounds, especially puncture wounds, are a common route of transmission for the spores.
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