The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway and shouting at other clients. What is the priority action of the nurse?
Attempt to deescalate the client.
Continue to observe the client for increased agitation.
Offer medications to help the client control behavior.
Ensure safety in the environment for the client and others.
The Correct Answer is D
A. Attempting to deescalate the client is important, but ensuring immediate safety is the top priority.
B. Continuing to observe the client may lead to a further escalation of the situation. Safety measures should be taken first.
C. While offering medications may be necessary, ensuring safety is the immediate priority before any interventions are implemented.
D. Ensuring the safety of the client and others is the priority in situations of escalating agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Neologisms refer to made-up words or phrases that have meaning only to the individual. The client's response does not include invented terms but rather consists of real words that are nonsensically grouped.
B. Echolalia is the repetition of words or phrases spoken by others. The client's response does not reflect repetition of the nurse's words but rather a disjointed response of their own.
C. Pressured speech involves rapid and often incoherent speech that reflects a sense of urgency. The client's response lacks the rapid flow characteristic of pressured speech.
D. Clang association is characterized by speech in which the individual connects words based on their sound rather than their meaning. The client's response ("medications, abbreviations, deviations, mediations") demonstrates this pattern, as the words are linked by similar sounds rather than by content or coherent thought.
Correct Answer is C
Explanation
A. A depressant Depressants typically slow down the central nervous system, leading to
symptoms like sedation, slowed heart rate, and reduced blood pressure. The symptoms described in the question, such as tachycardia, hypertension, restlessness, and agitation, are not
characteristic of depressant use.
B. An opioid Opioids primarily lead to central nervous system depression, resulting in symptoms like respiratory depression, sedation, and decreased heart rate. The symptoms described in the question, such as tachycardia and restlessness, are not typical of opioid use.
C. A stimulant Stimulants, such as amphetamines or cocaine, lead to increased activity in the central nervous system, resulting in symptoms like tachycardia, hypertension, restlessness, and agitation. These symptoms align with the presentation described in the question.
D. An inhalant Inhalants can lead to a variety of effects, including dizziness, confusion, and sometimes increased heart rate. However, they are not typically associated with the specific symptoms of tachycardia, hypertension, restlessness, and agitation described in the question.
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