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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A) Incorrect. The ability to accomplish activities of daily living is not specific to the diagnosis of schizophreniform disorder.

B) Incorrect. The client's emotional state or demeanor is not a specific indicator of schizophreniform disorder.

C) Correct. Schizophreniform disorder is characterized by the presence of hallucinations,
delusions, and other psychotic symptoms for less than six months. It is considered a provisional diagnosis while the condition is still in its early stages.

D) Incorrect. Euphoria and excessive energy are not specific features of schizophreniform disorder.

A. Hallucinogen B. Hypnotic C. Opioid D. Sedative

Correct Answer is A

Explanation

A) Correct. Ecstasy, also known as MDMA (3,4methylenedioxymethamphetamine), belongs to the hallucinogen class of drugs. It produces altered perceptions and sensations.

B) Incorrect. Hypnotics are drugs that promote sleep.
C) Incorrect. Opioids are a class of drugs that include substances like heroin and prescription pain medications.

D) Incorrect. Sedatives are drugs that calm or soothe and can also induce sleep.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is A

Explanation

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