A nurse receives report that a client has been pacing the hallway continuously for almost twenty-four hours and talking excessively.
Which action is the priority?
Maintain trust and avoid behaviors that may increase agitation.
Order the client to go to their room & alert security.
Tell the client to sit down or risk isolation and loss of privileges.
Sedate the client after collecting a lithium level.
The Correct Answer is A
Maintain trust and avoid behaviors that may increase agitation. This is because the client is likely experiencing a manic episode, which is characterized by increased activity, rapid speech, and decreased need for sleep. The nurse should use a calm and supportive approach, provide a safe and structured environment, and avoid confrontation or criticism.
Choice B is wrong because ordering the client to go to their room and alerting security would escalate the situation and violate the client’s rights.
Choice C is wrong because telling the client to sit down or risk isolation and loss of privileges would be threatening and punitive, which could increase the client’s agitation and anger.
Choice D is wrong because sedating the client after collecting a lithium level would be premature and inappropriate without a physician’s order and without assessing the client’s vital signs, mental status, and medication history. Lithium is a mood stabilizer that can cause toxicity if the level is too high.
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Related Questions
Correct Answer is C
Explanation
On a regular schedule around the clock. This is because when pain is present for more than 12 hours a day, analgesic dosages are best administered around the clock rather than on an as-needed basis.
Choice A is wrong because waiting for the client to exhibit physiologic symptoms of pain may delay the administration of analgesics and cause unnecessary suffering. Physiologic symptoms of pain are not always reliable indicators of pain intensity or quality.
Choice B is wrong because administering analgesics prior to painful activities may not provide adequate pain relief throughout the day. Painful activities may vary depending on the client’s condition and preferences.
Choice D is wrong because relying on the client’s request may not ensure optimal pain management. Some clients may be reluctant to ask for analgesics due to fear of addiction, side effects, or being perceived as weak.
Correct Answer is C
Explanation
The nurse should complete an incident report when he or she contaminates and discards two indwelling catheters during the insertion procedure. This is because an incident report is a tool for documenting any event that is not consistent with the routine operation of a health care unit or the routine care of a client. An incident report helps to identify potential risks and improve quality and safety.
Choice A is wrong because not completing the care plan for a newly admitted client before leaving the unit is not an incident that requires reporting.
It is a matter of time management and prioritization.
Choice B is wrong because recording a client’s refusal to take prescribed medication on the chart is not an incident that requires reporting.
It is a part of the nursing documentation and communication.
Choice D is wrong because experiencing back pain after moving a client up in the bed is not an incident that requires reporting.
It is a personal injury that may be related to improper body mechanics or ergonomics.
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