A nurse is caring for a client who is displaying combative behavior. Which of the following actions should the nurse take first?
Place the client in restraints.
Escort the client to a place of seclusion.
Offer the client PRN medication,
Offer the client choices for a diversionary activity.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Wrap the dialysate with a heating pad before instillation: Warming the dialysate to body temperature helps prevent abdominal cramping and promotes comfort during infusion. It should be warmed using a heating pad, not a microwave, to ensure safe, even heating.
B. Use clean technique when performing the procedure: Peritoneal dialysis requires strict aseptic technique to prevent peritonitis, a serious infection. Clean technique is not sufficient for this sterile procedure and increases infection risk.
C. Advance the catheter into the peritoneum to promote drainage: The catheter should never be advanced by the client. It is surgically placed and should remain secure; any manipulation can cause injury or dislodgment.
D. Lie in the same position throughout the procedure: Changing positions may actually help facilitate better drainage. Clients are often encouraged to move or reposition slightly if drainage is sluggish. Remaining in one position is not necessary.
Correct Answer is C
Explanation
A. Increased glucose level: CSF glucose levels are typically normal in multiple sclerosis. An increase in glucose is more commonly associated with systemic hyperglycemia or specific infections, not demyelinating diseases like MS.
B. Decreased lactic acid level: A decreased lactic acid level is not a characteristic finding in multiple sclerosis. Lactic acid in CSF is more relevant in differentiating types of infections, such as bacterial versus viral meningitis.
C. Increased protein level: Elevated protein in the CSF is a common finding in multiple sclerosis, often due to increased immunoglobulin production and the presence of oligoclonal bands, reflecting immune system activity in the CNS.
D. Decreased WBC count: While a mild increase in WBC count may be seen in MS, a decreased WBC count is not typical or diagnostic of the disease. Leukocyte levels in CSF are usually normal or slightly elevated in MS.
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