A nurse on a mental health unit is assisting with the care of a client.
The nurse is continuing to assist with the care of the client. Select the four actions the nurse should take.
Ask the provider for a PRN prescription for restraints.
Administer diazepam when the client exhibits anxiousness.
Place the client in a room near the nurse's station.
Determine if the client is experiencing command hallucinations.
Establish clear limits for expected behaviors.
Correct Answer : B,C,D,E
A. Ask the provider for a PRN prescription for restraints: Restraints should only be used as a last resort when there is an imminent risk of harm to the client or others. In this situation, it is essential to first attempt to manage the client's anxiety and behavior through de-escalation strategies and appropriate interventions.
B. Administer diazepam when the client exhibits anxiousness: Diazepam can help manage anxiety and agitation, which is crucial for the client's safety and comfort. Monitoring for signs of anxiety allows for timely intervention with the prescribed medication.
C. Place the client in a room near the nurse's station: Keeping the client close to the nurse's station allows for increased monitoring and ensures that staff can respond quickly if the client's behavior escalates. This helps maintain safety for both the client and others on the unit.
D. Determine if the client is experiencing command hallucinations: Assessing for command hallucinations is important, especially given the client's recent aggressive behavior. Understanding the presence of such hallucinations can guide the treatment plan and safety measures.
E. Establish clear limits for expected behaviors: Setting clear expectations for behavior helps the client understand acceptable conduct and promotes a safer environment. This can be particularly important for clients with paranoid personality disorder who may struggle with interpersonal relationships.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Stimulants: While stimulants can cause symptoms such as increased energy, agitation, and paranoia, the specific combination of paranoia, visual disturbances (such as talking to the wall), and altered perception is more indicative of hallucinogen use.
B. Anabolic steroids: Anabolic steroids primarily affect physical strength and body composition, and while they can lead to aggressive behavior, they do not typically cause the acute symptoms of paranoia and visual hallucinations seen in this client.
C. Hallucinogens: The symptoms described, including paranoia, dizziness, vomiting, and visual disturbances (evidenced by the client talking to the wall), are characteristic of hallucinogen use. Hallucinogens can induce altered perceptions and significant changes in mood and thought processes, leading to behaviors like the ones exhibited by the client.
D. Opioids: Opioids generally cause sedation, respiratory depression, and a sense of euphoria, but they do not typically produce paranoia or hallucinations. The symptoms presented by the client do not align with opioid intoxication.
Correct Answer is B
Explanation
A. Naloxone: Naloxone is an opioid antagonist used to reverse opioid overdoses. It is not indicated for alcohol withdrawal and does not address the symptoms associated with this condition.
B. Benzodiazepines: Benzodiazepines are commonly prescribed to manage alcohol withdrawal symptoms. They help reduce anxiety, prevent seizures, and alleviate autonomic instability during the withdrawal process, making them the first-line treatment in such cases.
C. Diphenhydramine: Diphenhydramine is an antihistamine that may be used for allergy symptoms or as a sleep aid. It is not indicated for managing alcohol withdrawal symptoms and does not address the critical issues associated with this condition.
D. Methadone: Methadone is a medication used for opioid dependence and is not appropriate for treating alcohol withdrawal. It is specifically designed to manage opioid addiction and does not have a role in alcohol withdrawal management.
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