A nurse is leading a medication education group for several clients. A client who is sometimes violent becomes angry and begins yelling at others in the group. Which of the following actions should the nurse take? Select all that apply.
Offer the client a PRN dose of lorazepam.
Ask the client open-ended questions about the behavior.
Stand directly in front of the client.
Move others away from the client.
Speak to the client in an aggressive tone of voice.
Correct Answer : A,D
Choice A reason: Offering the client a PRN dose of lorazepam is appropriate because benzodiazepines are often prescribed for acute agitation and anxiety. Administering medication can help de-escalate the situation, reduce the risk of violence, and restore calm. This intervention directly addresses the client’s agitation and promotes safety for both the client and others.
Choice B reason: Asking open-ended questions during an episode of acute agitation is not appropriate. Open-ended questions require thought and elaboration, which can increase frustration and escalate aggression. In crisis situations, communication should be simple, direct, and focused on safety rather than exploration.
Choice C reason: Standing directly in front of the client is unsafe because it places the nurse in a vulnerable position if the client becomes physically aggressive. The nurse should maintain a safe distance and stand at an angle to reduce the risk of harm.
Choice D reason: Moving others away from the client is correct because it protects the safety of the group. Removing potential targets of aggression reduces the risk of injury and helps de-escalate the environment. This is a critical safety measure in managing violent behavior.
Choice E reason: Speaking in an aggressive tone of voice is inappropriate because it escalates tension and may provoke further aggression. The nurse should use a calm, firm, and non-threatening tone to de-escalate the situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Sleeping only 4 hours is common during mania and contributes to exhaustion, but it is not immediately life-threatening.
Choice B reason: Refusing to shower reflects poor self-care, which is expected in mania, but it does not pose an acute medical risk.
Choice C reason: Eating half a snack shows reduced intake but is not as urgent as fluid refusal.
Choice D reason: Refusing fluids is the priority because dehydration can quickly lead to severe complications such as electrolyte imbalance, cardiac dysrhythmias, and renal impairment. This requires immediate intervention.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}
Explanation
Rationale for PET scan: A PET scan of the head is anticipated because the client is showing progressive cognitive decline, memory loss, and disorientation. Neuroimaging is appropriate to rule out structural or metabolic causes such as stroke, tumors, or neurodegenerative disease. This helps differentiate dementia from other neurological conditions.
Rationale for physical examination: A physical exam is anticipated because it provides a baseline assessment of the client’s overall health, identifies comorbid conditions, and evaluates neurological status. Physical findings can guide further diagnostic testing and management.
Rationale for MMSE: Administering the Mini Mental State Examination is anticipated because it is a standardized tool used to assess cognitive function, memory, orientation, and problem-solving ability. Given the client’s symptoms of forgetfulness, disorientation, and difficulty with daily tasks, the MMSE will help quantify cognitive impairment and track progression.
Rationale for medication review: Reviewing all prescribed and over-the-counter medications is anticipated because certain drugs can contribute to confusion, memory loss, or delirium. Polypharmacy and inappropriate medication use are common in older adults and can mimic or worsen dementia symptoms. Identifying and adjusting medications is a critical step in care.
Rationale for inpatient behavioral health admission: Admission to a behavioral health unit is not indicated at this stage. The client’s symptoms are consistent with progressive dementia rather than an acute psychiatric crisis. The focus should be on diagnostic evaluation, outpatient management, and support rather than psychiatric hospitalization
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.