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 D
Explanation
Choice A reason: A bedside table 2 feet away hinders reach, increasing fall risk. It should be closer for safe access to essentials in bed.
Choice B reason: Dim lighting obscures hazards, raising fall risk. Bright, even illumination is needed to enhance visibility for a client prone to falling.
Choice C reason: Area rugs on slick floors create tripping hazards, worsening fall risk. Secure or remove them to stabilize footing for safety.
Choice D reason: Moving the bed downstairs eliminates stair falls, a major risk. It’s a key environmental adaptation for safe mobility in at-risk clients.
Correct Answer is C
Explanation
Choice A reason: Exiting during a chemical disaster risks inhalation of toxic fumes outdoors. Scientifically, sheltering in place seals against contaminants, as evacuation exposes lungs to higher pollutant concentrations, contradicting safety protocols for chemical exposure management.
Choice B reason: Fans and AC circulate outside air, drawing in chemical toxins. Scientifically, this breaches indoor air integrity during disasters, increasing respiratory exposure to hazardous particles, opposing evidence-based sealing strategies for protection against airborne threats.
Choice C reason: Covering registers with plastic and tape seals ventilation, preventing chemical entry. Scientifically, this aligns with shelter-in-place protocols, minimizing indoor contamination by blocking airflow paths, a critical step to reduce inhalation risks during outdoor chemical disasters.
Choice D reason: Opening fireplace dampers invites chemical-laden air inside, breaching safety. Scientifically, this counters containment principles, as open vents increase exposure to toxic gases, undermining respiratory protection essential in disaster scenarios per environmental health guidelines.
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