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 B
Explanation
A) Incorrect. Naltrexone does not primarily target withdrawal symptoms. It works by blocking the pleasurable effects of alcohol, reducing the reinforcement that leads to craving.
B) Correct. Naltrexone is an opioid antagonist that reduces the craving for alcohol. It does this by blocking the opioid receptors in the brain, which are involved in the pleasurable effects of
alcohol consumption.
C) Incorrect. Naltrexone is not primarily used to manage anxiety. Its main purpose is to help individuals reduce or stop their alcohol intake.
D) Incorrect. Naltrexone is not primarily used to treat depressive symptoms. Its focus is on reducing alcohol cravings.
Correct Answer is C
Explanation
A) Incorrect. While discussing various topics is important, providing continuity of care is more crucial in creating a therapeutic environment for clients with paranoia and schizophrenia.
B) Incorrect. Focusing on client strengths rather than weaknesses is generally a more effective approach in mental health care.
C) Correct. Providing continuity of care by assigning the same staff helps build trust and a sense of security for clients, especially those with paranoia and schizophrenia.
D) Incorrect. While it's important to establish boundaries, allowing the client to solely determine them may not always be in their best interest.
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