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 A
Explanation
Choice A reason: Recording the client’s behavior every 15 minutes while in restraints is correct because frequent documentation ensures safety, monitors the client’s physical and psychological status, and provides evidence that restraints are being used appropriately.
Choice B reason: Securing restraints to the bed rail is unsafe because bed rails move and can cause injury. Restraints should be secured to the bed frame using a quick-release knot, not a slip knot, to allow rapid removal in emergencies.
Choice C reason: Raising all four bedrails is considered a restraint if it restricts the client’s freedom of movement. This statement is incorrect because it misrepresents restraint guidelines.
Choice D reason: Assessing a restrained client only once every 2 hours is insufficient. Clients must be assessed at least every 15 minutes for safety, circulation, and comfort. Two-hour checks would not meet safety standards.
Correct Answer is D
Explanation
Choice A reason: While this statement is true, it is confrontational and does not address the nurse’s legal and professional responsibility. Nurses must prioritize child safety and follow mandated reporting laws rather than offering judgmental statements.
Choice B reason: Asking the parent why they think it will not happen again is inappropriate. It places responsibility on the parent and may minimize the seriousness of the abuse. The nurse’s role is to protect the child, not to debate with the caregiver.
Choice C reason: Reporting suspected child abuse is not optional or left to the parent. It is a legal obligation of healthcare providers. Suggesting that it is the parent’s responsibility misrepresents the nurse’s duty and could result in failure to protect the child.
Choice D reason: Informing the parent that the child will be privately interviewed is appropriate. This ensures the child’s voice is heard without parental influence and allows professionals to assess the situation accurately. It also communicates the seriousness of the incident while maintaining professionalism
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