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 B

Explanation

Choice A reason: Social workers address psychosocial needs, not drug interactions. Medication queries require clinical expertise beyond their scope in this context.

Choice B reason: Advanced practice nurses have prescribing and pharmacology knowledge, ideal for assessing interactions. They’re the best referral for this clinical question.

Choice C reason: Patient care technicians assist with basic care, lacking drug interaction training. They can’t evaluate complex medication profiles adequately here.

Choice D reason: Psychologists focus on mental health, not pharmacokinetics. They lack the medical expertise to address physical drug interaction concerns effectively.

A. "Droplet precautions require that I wear a gown and gloves when providing client care." B. "Following a blood spill, I should use a bleach solution with a ratio of 1 to 20." C. "Soiled dressings should be placed in a biohazard trash receptacle." D. "For a client who has Clostridium difficile, I will cleanse my hands with an alcohol-based rub."

Correct Answer is C

Explanation

Choice A reason: Droplet precautions need a mask, not always gown and gloves, unless contact is likely. Scientifically, this overstates requirements, as droplet spread (e.g., flu) prioritizes respiratory protection, indicating partial misunderstanding of PPE specifics.

Choice B reason: Bleach at 1:20 is too dilute; 1:10 is standard for blood spills. Scientifically, this weakens disinfection, as higher chlorine concentration kills pathogens like hepatitis, showing incorrect grasp of spill management protocols.

Choice C reason: Biohazard disposal for soiled dressings prevents pathogen spread, aligning with infection control. Scientifically, this ensures safe waste handling, as dressings may harbor bacteria or viruses, reflecting accurate understanding of standard precautions.

Choice D reason: Alcohol doesn’t kill C. difficile spores; soap and water are required. Scientifically, this misapplies hand hygiene, as spore-forming bacteria resist alcohol, indicating a key error in infection control knowledge for this pathogen.

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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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Correct Answer is B

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Correct Answer is C

Explanation

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