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A nurse is caring for a client who is displaying combative behavior. Which of the following actions should the nurse take first?

A.

Place the client in restraints.

B.

Escort the client to a place of seclusion.

C.

Offer the client PRN medication,

D.

Offer the client choices for a diversionary activity.

Answer and Explanation

The Correct Answer is D

A. Place the client in restraints: Restraints are a last-resort intervention and should only be used when the client poses an immediate danger to self or others and less restrictive methods have failed. Initiating restraints first violates the client’s rights and can escalate agitation.

B. Escort the client to a place of seclusion: Seclusion, like restraints, is a restrictive intervention that should only be used after less invasive strategies have been attempted. Removing a client without consent may also worsen their aggression or fear.

C. Offer the client PRN medication: While medication may be helpful in calming the client, it should not be the first step unless the client is in imminent danger or past strategies have failed. Attempting non-pharmacologic interventions first respects the client’s autonomy.

D. Offer the client choices for a diversionary activity: This is the least restrictive intervention and a therapeutic first approach. Providing the client with options promotes autonomy, can redirect aggression, and helps prevent escalation through calming, client-centered communication.


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Related Questions

Correct Answer is B

Explanation

A. "Someone comes over every day to help." While having help can be beneficial, this statement alone does not reflect how the client is emotionally or psychologically coping with the transition to parenthood. It may also indicate dependence rather than adjustment.

B. "We started having date nights." Re-establishing routines like date nights suggests that the client is adapting to their new role while maintaining a healthy relationship. It reflects positive coping and balance between parenting responsibilities and personal well-being.

C. "I am sad most of the time." Persistent sadness may indicate postpartum depression, which requires further assessment and intervention. It does not reflect healthy coping or adjustment to parenthood.

D. "My partner wants more intimacy." This statement focuses on the partner’s needs and does not indicate the client’s coping ability. It may even suggest stress or imbalance in the relationship if the client feels pressured or unready.

Correct Answer is A

Explanation

A. Abdominal distention: Paralytic ileus is a temporary cessation of bowel motility, often following surgery, especially abdominal or orthopedic procedures. Distention occurs due to accumulation of gas and fluid in the intestines and is a key indicator.

B. Oliguria: Reduced urine output may suggest dehydration or kidney issues but is not specific to paralytic ileus. It does not directly reflect gastrointestinal motility or function.

C. Dizziness: Dizziness can result from various causes like blood loss, medication, or orthostatic hypotension, but it is not a clinical sign of paralytic ileus and does not relate to bowel activity.

D. Watery stool: Watery or loose stools are more characteristic of diarrhea or bowel irritation. In paralytic ileus, bowel movement is typically absent, and stool passage is minimal or stopped.

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