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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Dry mucous membranes signal dehydration, not hyperkalemia directly. High potassium affects cardiac and nerve function, not mucosal hydration status in renal failure.

Choice B reason: Hyperactive reflexes occur in hypocalcemia, not hyperkalemia. Excess potassium depresses nerve and muscle activity, often reducing reflexes instead of enhancing them.

Choice C reason: Trousseau’s sign indicates hypocalcemia, with carpal spasm from cuff pressure. Hyperkalemia in renal failure doesn’t trigger this; it’s a calcium issue.

Choice D reason: Irregular heart rate, like bradycardia or arrhythmias, stems from hyperkalemia’s effect on cardiac conduction. In renal failure, potassium excess disrupts rhythms critically.

A. "I need to be careful when standing up from bed." B. "I should limit my intake of leafy green vegetables." C. "I should expect some weight loss." D. "I may experience loss of taste."

Correct Answer is A

Explanation

Choice A reason: Metoprolol, a beta-blocker, lowers BP, causing orthostatic hypotension. Caution when standing prevents falls, showing grasp of this key side effect.

Choice B reason: Leafy greens affect warfarin, not metoprolol. No dietary restriction applies, so this reflects confusion about beta-blocker side effects.

Choice C reason: Weight gain, not loss, may occur with metoprolol from fluid retention. Expecting loss misinterprets its metabolic impact, indicating misunderstanding.

Choice D reason: Taste loss isn’t a metoprolol effect; it’s linked to other drugs. This shows incorrect attribution of side effects to the medication.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is in renal failure. Which of the following findings should the nurse identify as a manifestation of hyperkalemia?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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