An angry client has just thrown a chair across the room and is racing to pick up another chair to throw. Which is the most appropriate action by the nurse?

Call for an emergency response from trained personnel.

Calmly call the client by name and encourage verbal expression of anger.

Approach the client and firmly say. "Stop. put it down."

Assist the client to use problem-solving techniques instead of aggression

Answer and Explanation

The Correct Answer is A

The safety of both the client and others is the top priority in this situation. The client's aggressive behavior poses a significant risk, and immediate action is necessary. Calling for an emergency response from trained personnel, such as security or other staff members experienced in handling aggressive behavior, can help ensure the situation is properly managed and de-escalated in a safe manner.

Option B may not be appropriate in this situation, as trying to engage the client in verbal expression of anger while they are in an agitated and aggressive state can potentially escalate the situation further.

Option C is not recommended, as approaching the client in a confrontational manner may further escalate their anger and aggression.

Option D, while it may be beneficial in a different context and when the client is in a more stable state, is not appropriate when the client is actively engaged in aggressive behavior. The focus at this moment should be on ensuring the immediate safety of everyone involved.

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Correct Answer is C

Explanation

Objective data:

Blood pressure (can be measured by the nurse)

Cyanosis (can be observed by the nurse)

Petechiae (can be observed by the nurse)

So, the subjective data in this list is "Nausea." This is information that the client shares with the nurse about their symptoms or feelings.

The objective data includes A-"Blood pressure," B-"Cyanosis," and D-"Petechiae," which are findings that the nurse can measure or observe during the physical examination.

Correct Answer is ["260"]

Explanation

Step 1: Convert ½ cup of juice to mL. 1 cup = 240 mL ½ cup = 240 mL ÷ 2 = 120 mL Result: 120 mL

Step 2: Convert 3 oz of gelatin to mL. 1 oz = 30 mL 3 oz = 3 × 30 mL = 90 mL Result: 90 mL

Step 3: Convert 1 oz of an ice pop to mL. 1 oz = 30 mL 1 oz = 1 × 30 mL = 30 mL Result: 30 mL

Step 4: Ginger ale is already in mL. Result: 20 mL

Step 5: Add all the mL values together. 120 mL + 90 mL + 30 mL + 20 mL = 260 mL Result: 260 mL

The nurse should record the child’s fluid intake as 260 mL.

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An angry client has just thrown a chair across the room and is racing to pick up another chair to throw. Which is the most appropriate action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?

Correct Answer is C

Explanation

A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed ½ cup of juice, 3 oz gelatin. 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?

Correct Answer is ["260"]

Explanation

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