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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Elevation reduces swelling post-cast application, enhancing circulation. It’s a key step to prevent edema and discomfort in the right arm.
Choice B reason: Hair dryers risk burns or softening plaster; scratching tools are safer. This is incorrect and dangerous advice for cast care management.
Choice C reason: Covering delays drying, trapping moisture in plaster. It needs air exposure to harden, so this contradicts proper cast maintenance.
Choice D reason: Showering after 24 hr wets plaster, weakening it. Casts require protection from water, making this an inaccurate care instruction.
Correct Answer is B
Explanation
Choice A reason: Elevated ammonia relates to liver failure, not pancreatitis. Pancreatitis involves pancreatic enzyme leakage, not nitrogen metabolism. Scientifically, ammonia rises in hepatic encephalopathy, lacking relevance to pancreatic inflammation, making this an incorrect marker for the condition.
Choice B reason: Elevated lipase is a hallmark of pancreatitis, as inflamed pancreatic acinar cells release this enzyme into blood. Scientifically, it’s a specific diagnostic indicator, rising with tissue damage, aligning with pancreatitis pathophysiology for accurate clinical identification.
Choice C reason: Prolonged PT/INR reflects coagulopathy, often liver-related, not pancreatitis unless complicated by disseminated intravascular coagulation. Scientifically, this isn’t a primary marker, as pancreatitis targets digestion, not clotting, making it less expected in typical cases.
Choice D reason: Decreased albumin suggests chronic liver disease or malnutrition, not acute pancreatitis. Pancreatitis doesn’t directly impair protein synthesis. Scientifically, albumin drops over time, not acutely, misaligning with pancreatitis’s rapid inflammatory onset and diagnostic profile.
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