A nurse on a mental health unit observes a client yelling at another client. Which of the following actions should the nurse take first?

State expectations for the client's behavior.

Request security personnel restrain the client.

Place the client in seclusion.

Debrief staff members about the conflict.

Answer and Explanation

The Correct Answer is A

The correct answer is Choice A.

Choice A rationale: By stating expectations for the client’s behavior, the nurse is addressing the immediate situation and setting clear boundaries. This intervention allows the nurse to assertively communicate with the client, reminding them of appropriate behavior and potentially diffusing the situation 1.

Choice B rationale: Requesting security personnel to restrain the client should be a last resort, used only when the client poses a significant risk to themselves or others and all other de-escalation techniques have failed. Restraint can be traumatic and has potential physical and psychological risks.

Choice C rationale: Placing the client in seclusion is another measure that should be used sparingly and only when necessary for the safety of the client or others. It’s important to try less restrictive measures first, such as verbal de-escalation techniques or offering a quiet, private space where the client can regain control.

Choice D rationale: Debriefing staff members about the conflict is an important step, but it should not be the first action. The immediate priority is to ensure the safety of all clients and to de-escalate the situation.

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Correct Answer is ["B","C","D"]

Explanation

It is not appropriate for the nurse to threaten the client's child with reporting for maltreatment without further assessment and evidence.

Asking the client's child to provide details regarding the client's fractured arm will provide additional information about the client's injury and help the nurse assess the potential for abuse or neglect.

Discussing respite care options with the client's child may help alleviate any caregiver stress or burden, and ensure the client's continued care and safety.

Speaking to the client privately will help establish trust and rapport, and allow the client to disclose any

concerns or issues that they may not feel comfortable sharing in front of their child.

Providing legal advice regarding power of attorney is not within the scope of nursing practice and should be referred to a legal professional. Additionally, the client's capacity to make decisions and appoint a power of attorney should be assessed before providing such advice.

A. "Tilt your head forward while inhaling." B. "Exhale immediately after inhaling." C. "Close your mouth around the mouthpiece." D. "Take three quick breaths while depressing the canister."

Correct Answer is C

Explanation

Instruct the client to close their mouth tightly around the mouthpiece of the inhaler. This ensures that the medication is delivered directly into the lungs and minimizes the amount of medication escaping into the surrounding environment.

The correct technique for using a metered-dose inhaler does not involve tilting the head forward.

Instead, the client should keep their head in a neutral position while using the inhaler. After inhaling the medication from the inhaler, it is recommended to hold the breath for about 10 seconds before exhaling. This allows the medication to be fully deposited in the lungs and absorbed effectively.

The proper technique for using an albuterol metered-dose inhaler involves taking a slow and deep breath. The client should depress the canister once at the beginning of inhalation and continue to inhale slowly and deeply to ensure adequate medication delivery.

It is important for the nurse to demonstrate and observe the client's technique while using the inhaler to ensure proper administration.

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A nurse on a mental health unit observes a client yelling at another client. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","D"]

Explanation

A nurse is reinforcing teaching with a client who is about to start using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

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