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: Hand tremors are not a primary symptom of anaphylaxis, which epinephrine treats. Tremors may occur from anxiety or other conditions, but epinephrine’s beta-adrenergic effects target airway dilation and vasoconstriction, not neurologic stabilization, making this unrelated to its acute therapeutic purpose.

Choice B reason: Shortness of breath, common in anaphylaxis, results from bronchoconstriction and airway swelling. Epinephrine acts on beta-2 receptors to relax bronchial smooth muscle, reversing dyspnea. This aligns with its primary use in allergic reactions, restoring oxygenation by counteracting histamine-induced distress.

Choice C reason: Nausea may accompany anaphylaxis due to systemic histamine release, but epinephrine does not directly treat it. Its focus is on reversing airway and vascular collapse, not gastrointestinal symptoms, which are secondary, making this an incidental, not primary, target of action.

Choice D reason: Hyperglycemia is not an anaphylactic symptom; epinephrine may raise blood sugar as a side effect via glycogenolysis, but this is irrelevant to its emergency use. It targets airway obstruction, not metabolic states, making this a misaligned choice for its therapeutic intent.

A. "Carry your newborn back to the nursery in your arms when you need to rest." B. "Request that the nurses show their nursing license prior to removing your newborn from the room." C. "Alert the staff if any of your newborn’s identification bands are missing." D. "Leave your newborn in the bassinet in your room while you use the bathroom."

Correct Answer is C

Explanation

Choice A reason: Carrying the newborn to the nursery risks dropping due to postpartum fatigue or weakness. Scientifically, this increases injury potential, as maternal strength is compromised early postpartum, making it an unsafe practice compared to staff-assisted transport protocols.

Choice B reason: Requesting licenses is impractical and delays care; ID badges suffice for security. Scientifically, this overcomplicates verification, as hospitals use standardized identification, reducing abduction risk effectively without burdening staff or compromising timely newborn management.

Choice C reason: Missing ID bands threaten security, risking mix-ups or abduction. Alerting staff ensures immediate correction, aligning with scientific safety protocols, as dual identification (mother and baby) is critical postpartum to prevent errors or unauthorized removal in healthcare settings.

Choice D reason: Leaving the newborn unattended in the bassinet risks theft or falls, especially in an unsecured room. Scientifically, constant supervision or staff notification is safer, as postpartum units prioritize vigilance to protect vulnerable infants from preventable harm.

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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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Explanation

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Correct Answer is C

Explanation

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