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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a. Recommend the AP come back later when the record is available:
This option delays the documentation process unnecessarily and may inconvenience the AP.
It doesn't address the issue of maintaining patient confidentiality and accurate documentation.
b. Log out so the AP can log in to document the vital signs:
This is the correct choice as it ensures that each individual's documentation is attributed to the correct user.
It maintains patient confidentiality and adheres to HIPAA regulations.
It allows the AP to complete their task efficiently while preserving the integrity of the electronic record.
c. Offer to chart the vital signs for the AP:
This option involves the nurse taking over the responsibility of documenting the vital signs for the AP, which could lead to confusion and potential errors.
It's not the most appropriate solution as it may not be feasible for the nurse to document the vital signs accurately without directly measuring them.
d. Allow the AP to document the vital signs prior to logging out:
Allowing the AP to document vital signs under the nurse's login compromises the integrity of the electronic record and violates HIPAA regulations.
It's not an acceptable practice as it can lead to inaccuracies in the documentation and compromises patient confidentiality.
Correct Answer is B
Explanation
a. A visitor experiences a minor burn after spilling coffee:
This situation does not present an ethical dilemma. It is a minor accident that can be addressed through appropriate first aid and safety measures.
b. A parent wants her 14-year-old adolescent to receive radiation treatment against his will:
This situation involves a conflict between parental authority and the autonomy of the adolescent. It raises questions about the adolescent's capacity to make medical decisions, the role of parental consent, and the rights of the adolescent to refuse treatment. Therefore, it represents an ethical dilemma.
c. A nurse witnesses another nurse administer an incorrect medication:
While this situation involves patient safety and professional responsibility, it does not inherently pose an ethical dilemma. It is a matter of patient safety and adherence to professional standards rather than conflicting moral principles.
d. A client receives an operation on the wrong side of her body:
This situation represents a serious medical error and a violation of patient safety protocols. While it may have ethical implications related to accountability, negligence, and patient harm, it primarily involves issues of medical error rather than a true ethical dilemma.
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