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 C

Explanation

Choice A reason: Antibiotics treat bacteria, not herpes, a viral infection. This is ineffective and risks resistance, making it an inappropriate intervention for simplex outbreaks.

Choice B reason: Povidone-iodine is harsh, delaying herpes healing by irritating lesions. Antivirals and gentle care are preferred, so this isn’t recommended for skin eruptions.

Choice C reason: OTC ointments can worsen herpes or delay healing without antiviral properties. Avoiding them ensures proper treatment, aligning with outbreak management guidelines.

Choice D reason: Disposable thermometers prevent cross-infection but don’t treat herpes directly. This is a general precaution, not a specific intervention for outbreak care.

A. Dry mucous membranes B. Hyperactive reflexes C. Trousseau's sign D. Irregular heart rate

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.

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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

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