A nurse is caring for multiple clients on a mental health unit.
Which of the following clients should the nurse attend to first?.
A client who has bipolar disorder and is continuously pacing at the end of the hall.
A client who is standing in her room, yelling obscenities and throwing her clothes.
A client in the dayroom who is screaming at other clients about what is on the television.
A client who is repeatedly approaching the nurses' station to request medication for his anxiety.
The Correct Answer is B
Choice A rationale:
While pacing can indicate anxiety, this client is not currently a threat to themselves or others.
Choice B rationale:
This client is exhibiting aggressive behavior and could potentially harm themselves or damage property.
Choice C rationale:
Although this client’s behavior is disruptive, it is not immediately dangerous.
Choice D rationale:
This client’s repeated requests indicate anxiety, but they are not in immediate danger.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Obtaining a prescription for haloperidol is not the first intervention the nurse should implement. Medication should be considered only after non-pharmacological interventions have been attempted.
Choice B rationale:
Taking the client to the seclusion room is not the first intervention the nurse should implement. Seclusion should be used only as a last resort when all other interventions have failed and the client is a danger to themselves or others.
Choice C rationale:
Verbally de-escalating the client is the first intervention the nurse should implement. This involves using calm, clear communication to help the client regain control of their emotions.
Choice D rationale:
Placing the client in restraints is not the first intervention the nurse should implement. Restraints should be used only as a last resort when all other interventions have failed and the client is a danger to themselves or others.
Correct Answer is D
Explanation
Choice A rationale:
Alcohol can interfere with sleep patterns and should not be used as a sleep aid.
Choice B rationale:
Napping can make it harder to fall asleep at night.
Choice C rationale:
Eating just before bedtime can cause discomfort and disrupt sleep.
Choice D rationale:
Limiting caffeine intake can help improve sleep, as caffeine is a stimulant that can interfere with the ability to fall asleep.
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