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A nurse is speaking with the sibling of a client who refuses to see visitors.
Which of the following actions should the nurse take?.

Encourage the client to visit with the sibling.

Tell the sibling the client does not want visitors.

Arrange for the sibling to visit the client in the dayroom.

Refer the sibling to the client's provider.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

It’s not appropriate to pressure the client into seeing visitors.

Choice B rationale:

It’s important to respect the client’s wishes and communicate them to the sibling.

Choice C rationale:

This could potentially cause distress for the client.

Choice D rationale:

While it might be helpful to involve the provider, the immediate issue can be addressed by the nurse.

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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.

A. Client confused and agitated. B. Appearance is disheveled. C. Mucous membranes dry D. client states, "Can you ask that person to leave my room?" E. Client is pointing to an empty chair F. Temperature 38.6°C (101.5°F) G. Blood pressure 158/96 mm Hg

Correct Answer is ["A","B","C","D","E","F","G"]

Explanation

The findings that require immediate follow-up are: Client confused and agitated: This could indicate a neurological issue or other serious condition that needs immediate attention.
Appearance is disheveled: This could suggest neglect or other issues that need to be addressed.
Mucous membranes dry: This could indicate dehydration which can be serious if not addressed promptly. Client states “Can you ask that person to leave my room?” Client is pointing to an empty chair: This could indicate hallucinations or other mental health concerns that need immediate attention.
Temperature 38.6°C (101.5°F): This is a fever and could indicate an infection or other medical condition that needs immediate attention.
Blood pressure 158/96 mm Hg: This is high and could indicate hypertension or other cardiovascular issues that need immediate attention.

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A nurse is speaking with the sibling of a client who refuses to see visitors. Which of the following actions should the nurse take?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is becoming increasingly agitated, anxious, and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?.

Correct Answer is C

Explanation

Correct Answer is ["A","B","C","D","E","F","G"]

Explanation

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A nurse is speaking with the sibling of a client who refuses to see visitors.
Which of the following actions should the nurse take?.