The nurse is assessing an inpatient client with a known history of violence. The client suddenly displays clenched fists. What additional behavior by the client would suggest that the aggression is escalating? The client:
refuses to eat lunch.
requests prn medications.
is pacing around the milieu.
sits in a group with their peers.
The Correct Answer is C
a. refuses to eat lunch. Refusal to eat lunch might indicate displeasure or upset but does not directly suggest escalating aggression.
b. requests prn medications. Requesting prn (as needed) medications typically indicates the client is aware of their distress and is seeking help, not escalating aggression.
c. is pacing around the milieu. Pacing can be a sign of increasing agitation and is often observed in clients who are escalating towards aggressive behavior. This physical activity can indicate restlessness and an inability to calm down.
d. sits in a group with their peers. Sitting in a group with peers suggests a level of social engagement and does not indicate escalating aggression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. Is pathological and warrants postponing the test: Not necessarily true. Mild anxiety is a normal human response to stressful situations. Postponing the test might reinforce avoidance behaviors.
b. May be transferred to classmates and result in test anxiety: While anxiety can be contagious in some situations, the nurse should focus on calming techniques for the individual experiencing it, not assuming it will spread.
c. is conducive to concentration and problem solving (Correct): Mild anxiety, also known as arousal, can heighten focus and alertness. This can be beneficial for tasks that require concentration, like tests. In some cases, it can improve cognitive function
d. Will interfere with cognitive ability: Extreme anxiety can be debilitating, but mild anxiety can actually enhance focus and performance in some situations.
Correct Answer is B
Explanation
a. Diphenhydramine: Diphenhydramine is an antihistamine that can also be used for its sedative properties to help calm an agitated client.
b. Ondansetron: Ondansetron is an antiemetic used to prevent nausea and vomiting, not for managing agitation or assaultive behavior. The nurse should question this order as it is not appropriate for the client's current symptoms.
c. Lorazepam: Lorazepam is a benzodiazepine used for its anxiolytic and sedative effects, making it appropriate for calming an agitated client.
d. Haloperidol: Haloperidol is an antipsychotic medication commonly used to manage severe agitation and aggressive behavior.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.