A nurse is caring for a client who wanders through the halls yelling obscenities at staff, other clients, and visitors. Which of the following action should the nurse take?
Administer a sedative to the client
Contact a family member to come and sit with the client
Place the client in a wheelchair with a lap tray
Keep the client in her room with the door closed
The Correct Answer is B
a. Administer a sedative to the client:
Administering a sedative may temporarily calm the client, but it should not be the first-line intervention, especially without a physician's order. Sedatives carry risks and should only be used when other interventions have been considered and deemed ineffective or when the client's behavior poses an immediate danger to themselves or others.
b. Contact a family member to come and sit with the client: could indeed be a valid first step. If a family member is available and able to assist, they could potentially calm the client without the need for isolation and reducing disruptive behavior. However, if this is not feasible, then ensuring the client’s safety through temporary isolation with frequent checks might be necessary.
c. Place the client in a wheelchair with a lap tray:
Placing the client in a wheelchair with a lap tray may restrict their movement and potentially exacerbate agitation or aggression. It does not address the underlying reasons for the behavior and may not be an appropriate intervention for managing wandering behavior.
d. Keep the client in her room with the door closed:
Isolating a client in their room could be considered a form of restraint or isolation and should be used with caution. This should be used only after other less restrictive measures have been tried and deemed ineffective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Prepare to administer antibiotics to the client.
This is the correct action. Cutaneous anthrax is typically treated with antibiotics such as ciprofloxacin, doxycycline, or amoxicillin. Administering antibiotics promptly is essential to prevent the progression of anthrax infection.
b. Wear an N95 respirator mask while caring for the client.
While respiratory protection is important in certain situations, such as when caring for clients with respiratory infections, cutaneous anthrax is not transmitted through respiratory droplets. Therefore, wearing an N95 respirator mask is not necessary when caring for a client with cutaneous anthrax.
c. Plan to administer an antiviral medication to the client.
Anthrax is caused by a bacterium, not a virus, so antiviral medications would not be effective in treating anthrax infection. Antibiotics are the mainstay of treatment for anthrax.
d. Place a surgical mask on the client during transfer to the unit.
Cutaneous anthrax does not spread from person to person through respiratory droplets, so placing a surgical mask on the client during transfer is not necessary for preventing transmission of the disease.
Correct Answer is A
Explanation
a. Contact the case manager to discuss discharge options: This is an appropriate action. The case manager can assist in assessing the client's needs and coordinating appropriate discharge arrangements, such as arranging for home health services or exploring alternative care options.
b. Request another family member assist the client’s partner with care: This may be a helpful action if there is another family member who can provide support. However, it's important to consider the availability and willingness of other family members to take on caregiving responsibilities.
c. Recommend the partner place the client in a long-term care facility: This option may be considered if the partner is unable to continue providing care and there are no other feasible options available. However, it should be discussed with the client and their partner and explored as one of several potential solutions.
d. Ask the provider to delay the client’s discharge home for a few more days: This may be appropriate if there are concerns about the client's safety or if additional time is needed to arrange for alternative care options. However, it's important to address the underlying issues contributing to the partner's inability to provide care and to explore long-term solutions.
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