A patient is pacing the hall near the nurse’s station, swearing loudly. What would be an appropriate initial intervention for the nurse?
Please be quiet and sit down in this chair immediately.
I’d like to talk with you about how you’re feeling right now.
You must go to your room and try to control yourself.
What is going on?
The Correct Answer is B
Choice A rationale
Telling the patient to be quiet and sit down immediately may seem like a quick solution, but it is not the most therapeutic response. This approach may come across as dismissive and authoritarian, which could escalate the patient’s agitation.
Choice B rationale
This is the most appropriate initial intervention. By expressing a desire to understand the patient’s feelings, the nurse opens up a line of communication and shows empathy. This can help de-escalate the situation and make the patient feel heard and understood.
Choice C rationale
Telling the patient to go to their room and control themselves can come across as dismissive and invalidating. It does not address the patient’s feelings or concerns and may escalate the situation.
Choice D rationale
Asking “What is going on?” is a good way to encourage the patient to express their feelings, but it may not be as effective as Choice B. The phrasing in Choice B is more direct and shows more empathy and concern for the patient’s emotional state.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Lability is characterized by rapid, often unpredictable changes in emotions.
Correct Answer is D
Explanation
Choice A rationale
Hypertensive crisis is a severe increase in blood pressure that can lead to a stroke. The symptoms of a hypertensive crisis can include a severe headache, nausea, and vomiting, but not typically dry mouth and constipation.
Choice B rationale
Increased prolactin levels in the bloodstream can cause symptoms such as breast enlargement, production of breast milk, and menstrual changes, but not typically dry mouth and constipation.
Choice C rationale
Central nervous system stimulation can cause symptoms such as restlessness, insomnia, and tremors, but not typically dry mouth and constipation.
Choice D rationale
Anticholinergic reactions can cause a wide range of symptoms, including dry mouth and constipation. These are common side effects of many medications, including Risperdal.
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