A nurse is working with a client who becomes combative and threatens other clients and staff. Which of the following actions should the nurse take?
Stand in front of the client to block them from others in the room.
Apply restraints according to the facility's standing order.
Ensure there are enough staff members available for assistance.
Obtain a PRN prescription for restraints from the provider.
The Correct Answer is C
Choice A reason: Standing in front risks escalation and injury; de-escalation needs space. Safety protocol prioritizes staff positioning away from a combative client’s reach.
Choice B reason: Standing orders for restraints vary; immediate application skips assessment. Ensuring staff support first allows safer, assessed intervention per guidelines.
Choice C reason: Adequate staff ensures safe de-escalation or restraint if needed. It’s the priority, reducing risk to all in a combative situation effectively.
Choice D reason: PRN restraint orders follow de-escalation attempts; staff availability precedes this. Immediate safety via numbers is critical before seeking prescriptions here.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Increased caloric intake contradicts methylphenidate’s appetite-suppressant effect, a stimulant for ADHD. It boosts dopamine and norepinephrine, enhancing focus, not hunger. This suggests ineffectiveness or misreporting, as the drug typically reduces eating, misaligning with its pharmacological action on behavior.
Choice B reason: A better grasp of reality is vague and unrelated to ADHD or methylphenidate’s core effects. The drug improves attention and impulse control, not perception of reality, which is more relevant to psychosis. This does not indicate efficacy for ADHD scientifically.
Choice C reason: Weight loss is a common side effect of methylphenidate due to appetite suppression, not a direct efficacy marker. While it may occur, it does not confirm improved ADHD symptoms like focus, making it secondary to the drug’s therapeutic goal in treatment.
Choice D reason: Completing homework on time reflects improved focus and impulse control, methylphenidate’s primary goals in ADHD. By increasing dopamine in the prefrontal cortex, it enhances executive function, enabling task completion, a direct measure of efficacy per scientific intent.
Correct Answer is C
Explanation
Choice A reason: Wiping yellow crusts disrupts healing; they’re normal post-Plastibell exudate. This shows misunderstanding, as crusts should remain until the ring detaches naturally.
Choice B reason: Snug diapers risk ring displacement or irritation in Plastibell care. Loose fitting is advised, so this indicates a lack of proper technique understanding.
Choice C reason: Applying pressure with gauze controls minor bleeding, a correct response in Plastibell care. It shows understanding of managing complications until medical help is sought.
Choice D reason: Antibiotic ointment isn’t routine for Plastibell; petroleum jelly is used instead. This reflects incorrect care knowledge, potentially causing irritation or infection.
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