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 A

Explanation

Choice A reason: Monitoring post-meals prevents purging, a common anorexia behavior. One hour ensures food retention, supporting nutritional recovery and countering compensatory actions effectively.

Choice B reason: Weighing every 2 days tracks trends, but daily is standard in anorexia to monitor refeeding risks like edema or cardiac strain more closely.

Choice C reason: Vital signs twice weekly miss acute changes in anorexia, like bradycardia from malnutrition. Daily checks are needed for safety during early treatment.

Choice D reason: Two hours per meal allows purging opportunities in anorexia. Shorter, supervised times prevent this, ensuring intake for nutritional rehabilitation success.

A. Hypersomnia B. High cholesterol C. Urinary tract infection D. Amyloid plaque

Correct Answer is C

Explanation

Choice A reason: Hypersomnia causes excessive sleep, not delirium’s acute confusion. It’s unrelated to the restlessness and disorientation seen in this client’s presentation.

Choice B reason: High cholesterol affects vessels, not acute brain function. It’s a chronic risk, not a trigger for delirium’s sudden cognitive shift here.

Choice C reason: UTIs in older adults often cause delirium via systemic inflammation and toxins. This matches the client’s disorientation and restlessness as a risk.

Choice D reason: Amyloid plaque links to Alzheimer’s, a chronic condition. Delirium is acute; plaque doesn’t explain the sudden onset in this scenario.

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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

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