A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?

Remain with the client.

Give to client a PRN sleeping medication,

Encourage the client to go back to bed.

Explore alternatives to pacing the floor with the client.

Answer and Explanation

The Correct Answer is A

Remaining with the client provides support and ensures their safety. The client's behavior indicates distress, and having a nurse nearby can help the client feel more comfortable and secure.

B. Give the client a PRN sleeping medication:

Explanation: Administering a sleeping medication should not be the first response, especially if the client is agitated. It's important to address the underlying cause of the agitation and consider other interventions before resorting to medication.

C. Encourage the client to go back to bed:

Explanation: Encouraging the client to go back to bed might not be effective if they are experiencing significant distress or anxiety. It's better to address their emotional state first before suggesting any changes in activity.

D. Explore alternatives to pacing the floor with the client:

Explanation: This is a reasonable course of action. Exploring alternatives to the client's current behavior can help address their distress and find ways to manage their emotions more effectively.

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Free Nursing Study Resources

Correct Answer is ["24"]

Explanation

To calculate the mL/hr for the heparin infusion, you can use the formula:

mL/hr = (Total units required per hour) / (Units/mL in the solution)

Given:

Total units required per hour = 1,200 U/hr

Units/mL in the solution = 25,000 U / 500 mL = 50 U/mL

Plugging in the values:

mL/hr = (1,200 U/hr) / (50 U/mL)

mL/hr = 24 mL/hr (rounded to the nearest tenth)

Therefore, the nurse should set the IV pump to deliver 24 mL/hr for the heparin infusion.

A. Explain the client that the behavior was unacceptable. B. Explore the truth of the client's statements. C. Set behavioral limits for the client. D. Establish a client relationship

Correct Answer is C

Explanation

A. Explain to the client that the behavior was unacceptable: While addressing the behavior is important, it is more effective to first establish clear limits and boundaries to prevent further incidents.

B. Explore the truth of the client’s statements: This step involves assessing the client's statements and understanding their perspective, which is important but can be done after setting behavioral limits.

C. Set behavioral limits for the client: Establishing clear behavioral limits is crucial for maintaining safety and order in the psychiatric unit. It helps ensure that the client understands what is expected of them and the consequences of unacceptable behavior. This is particularly important if the client has exhibited aggressive behavior, as it helps prevent further incidents and maintains a safe environment for everyone.

D. Establish a client relationship: Building a therapeutic relationship is essential for effective treatment, but it should be done in the context of a safe environment where clear behavioral expectations have already been established.

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A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["24"]

Explanation

A nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unit. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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