A nurse is caring for a client who is visibly agitated and talking loudly in a group therapy session. Which of the following actions should the nurse take first?

Place the client in seclusion.

Assist the client with understanding their needs.

Ask the client to identify what made them upset.

Administer lorazepam IM.

Answer and Explanation

The Correct Answer is C

Choice A reason: Seclusion is a last resort, not first, per de-escalation principles. It risks escalating agitation or trauma without addressing the cause. Scientifically, verbal intervention precedes restraint, as identifying triggers can calm the client, aligning with evidence-based psychiatric care prioritizing least restrictive measures.

Choice B reason: Assisting with needs is vague and secondary to identifying the agitation’s source. Without understanding the trigger, this lacks focus. Scientifically, pinpointing the upset first guides effective support, making this a follow-up, not initial, step in managing acute behavioral distress.

Choice C reason: Asking what upset the client de-escalates by engaging them, identifying triggers for targeted intervention. This aligns with scientific psychiatric practice, reducing agitation through communication before medication or seclusion, addressing the root cause effectively as the first step in evidence-based care.

Choice D reason: Administering lorazepam IM is premature without de-escalation attempts. It risks over-sedation or side effects, bypassing verbal strategies. Scientifically, medication follows failed non-pharmacological efforts per guidelines, making this a later option, not the first, in managing agitation safely and effectively.

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Correct Answer is C

Explanation

Choice A reason: Antibiotics treat bacteria, not herpes, a viral infection. This is ineffective and risks resistance, making it an inappropriate intervention for simplex outbreaks.

Choice B reason: Povidone-iodine is harsh, delaying herpes healing by irritating lesions. Antivirals and gentle care are preferred, so this isn’t recommended for skin eruptions.

Choice C reason: OTC ointments can worsen herpes or delay healing without antiviral properties. Avoiding them ensures proper treatment, aligning with outbreak management guidelines.

Choice D reason: Disposable thermometers prevent cross-infection but don’t treat herpes directly. This is a general precaution, not a specific intervention for outbreak care.

A. Document the infiltration B. Apply a warm compress C. Elevate the arm D. Stop the infusion

Correct Answer is D

Explanation

Choice A reason: Documenting infiltration records the event but does not address the immediate issue. Edema and coolness suggest fluid leakage into tissues, which can cause damage if not stopped. Documentation is secondary to halting the infusion, as it only logs data without mitigating the ongoing extravasation harming the client’s tissue integrity.

Choice B reason: Applying a warm compress may increase blood flow and reduce swelling later, but it does not stop the fluid leakage causing the edema. The priority is to cease the infusion to prevent further tissue damage from ongoing infiltration, making this a subsequent action rather than the first step.

Choice C reason: Elevating the arm can help reduce swelling by aiding venous return, but it does not address the source of the problem—fluid leaking from the IV. Stopping the infusion first prevents additional extravasation, as elevation alone cannot halt the ongoing tissue damage caused by the continuous fluid administration.

Choice D reason: Stopping the infusion is the priority because edema and coolness indicate infiltration, where IV fluid leaks into surrounding tissues. Ceasing the flow prevents further damage, such as tissue necrosis or nerve injury, which can occur if fluid continues to accumulate, making this the critical first step in management.

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A nurse is caring for a client who is visibly agitated and talking loudly in a group therapy session. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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