A nurse on a mental health unit notices that a client is becoming increasingly agitated and throws a table when he is unable to select the television (TV) channel. Which of the following should be a priority action by the nurse?
Attempt to talk the client down.
Administer a PRN antianxiety medication.
Place the client in a monitored seclusion room until he is calm.
Restrain the client to prevent injury to himself or others.
The Correct Answer is A
Choice A rationale:
Attempting to talk the client down is the priority action in this situation. Agitation can escalate to aggression or violence if not addressed appropriately. Engaging in therapeutic communication can help de-escalate the client's agitation, express understanding, and potentially find out the underlying cause of their distress. This approach prioritizes a non-pharmacological intervention.
Choice B rationale:
Administer a PRN antianxiety medication. While medication might be a consideration for managing agitation, it's generally not the first action to take. Non-pharmacological interventions, like therapeutic communication, should be attempted first to minimize the reliance on medications to manage behaviors.
Choice C rationale:
Place the client in a monitored seclusion room until he is calm. Placing a client in seclusion should be a last resort and should only be done when there's an immediate risk of harm to the client or others. In this scenario, the client's agitation doesn't seem to present an imminent danger, so seclusion would be an excessive and restrictive intervention.
Choice D rationale:
Restrain the client to prevent injury to himself or others. Restraint should be an absolute last resort and only used when there's an imminent risk of harm that cannot be managed in any other way. Restraint can escalate agitation and trauma for the client, as well as pose legal and ethical concerns. Therefore, it should only be used when all other options have been exhausted and safety is a critical concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C: "I'm hearing that you are concerned that it might turn out that you have cancer."
Choice A rationale:
Dismissing the client's concerns and saying there's no reason to worry is not empathetic. It invalidates the client's feelings and does not address their anxiety.
Choice B rationale:
While discussing concerns with the provider is important, it's not the most therapeutic initial response. The nurse should engage with the client's feelings before suggesting actions.
Choice C rationale:
This is the correct choice. Reflecting the client's concerns back to them shows empathy and encourages them to express their feelings. This approach opens up communication and allows the nurse to provide support.
Choice D rationale:
Asking the client why they think they might have cancer could come across as confrontational and dismissive. The focus should be on understanding their feelings rather than challenging their thoughts.
Correct Answer is B
Explanation
Choice A rationale:
Current rehabilitation for opiate addiction is not typically associated with Wernicke-Korsakoff syndrome. Wernicke-Korsakoff syndrome is primarily linked to chronic alcohol abuse and thiamine deficiency.
Choice B rationale:
A personal history of alcohol use disorder is directly associated with Wernicke-Korsakoff syndrome. This syndrome is caused by thiamine (Vitamin B1) deficiency, which is commonly seen in individuals who have a history of heavy and chronic alcohol consumption.
Choice C rationale:
Undergoing current treatment for HIV is not a typical factor associated with the development of Wernicke-Korsakoff syndrome. This syndrome's primary cause is thiamine deficiency resulting from alcohol misuse.
Choice D rationale:
Family history of Alzheimer's disease is not a characteristic linked to Wernicke-Korsakoff syndrome. These two conditions have different etiologies and clinical presentations. Wernicke-Korsakoff syndrome is caused by thiamine deficiency, while Alzheimer's disease is a neurodegenerative disorder.
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