The nurse notices a client wandering in the hospital hall giggling, with bizarre behavior that is annoying and frightening other clients. A priority in caring for her is to:

Encourage social interaction.

Discuss the bizarre behavior.

Give the client information about her illness.

Provide a safe environment.

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Encouraging social interaction might not be appropriate in this situation. The client’s bizarre behavior is already causing distress to others, and encouraging more interaction could exacerbate the problem. The priority should be to address the immediate safety and well-being of both the client and others. Once the client is in a safe environment, social interaction can be encouraged in a controlled and therapeutic manner.

Choice B Reason:

Discussing the bizarre behavior with the client might not be effective in the moment, especially if the client is not in a state to understand or engage in such a discussion. The primary focus should be on ensuring safety and stability before addressing specific behaviors. Once the client is calm and in a safe environment, discussions about behavior can be more productive.

Choice C Reason:

Providing information about the client’s illness is important for long-term management and understanding, but it is not the immediate priority in this situation. The client’s current state requires immediate intervention to ensure safety. Education about the illness can be provided once the client is stabilized and in a better position to comprehend the information.

Choice D Reason:

Providing a safe environment is the most immediate and crucial priority. The client’s behavior is not only distressing to others but could also pose a risk to herself and others. Ensuring the client is in a safe, controlled environment helps to prevent harm and allows for further assessment and appropriate interventions. Safety is always the first priority in managing acute behavioral disturbances.

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Correct Answer is D

Explanation

Choice D Reason: 21g 1.5 in (3.8 cm) needle to the right ventrogluteal area. Use Z-track technique.

Choice A Reason:

Using a 23-gauge, 1-inch needle for an intramuscular (IM) injection in the deltoid muscle is generally appropriate for adults. The deltoid muscle is a common site for IM injections, especially for small volumes of medication (up to 2 mL). The acromion process is a correct landmark for locating the deltoid muscle. However, the deltoid muscle is not the best site for larger volumes or more viscous medications. Additionally, the needle length might not be sufficient for individuals with more subcutaneous fat, potentially leading to suboptimal medication delivery.

Choice B Reason:

A 25-gauge, 0.5-inch needle is typically used for subcutaneous injections rather than intramuscular injections. The rectus femoris muscle can be used for IM injections, but it is not the preferred site due to the potential for increased pain and discomfort. Aspiration before injection is a debated practice; current guidelines suggest that aspiration is not necessary for most IM injections, except when injecting into the dorsogluteal site, which is not recommended due to the risk of hitting the sciatic nerve.

Choice C Reason:

A 27-gauge, 1.5-inch needle is appropriate for IM injections, and the vastus lateralis is a suitable site, especially for infants and young children. However, massaging the injection site after administering an IM injection is not recommended. Massaging can cause the medication to disperse into the subcutaneous tissue, reducing its effectiveness and potentially causing irritation or bruising.

Choice D Reason:

Using a 21-gauge, 1.5-inch needle for an IM injection in the ventrogluteal area is considered safe and effective. The ventrogluteal site is preferred for IM injections because it is free from major nerves and blood vessels, reducing the risk of injury. The Z-track technique is used to prevent medication from leaking into the subcutaneous tissue, ensuring that it remains in the muscle for proper absorption. This technique is particularly useful for medications that can stain or irritate the skin and subcutaneous tissue.

A. Slowed psychomotor activity B. Impaired attention and concentration C. Hallucinations and delusions D. Decreased alertness or responsiveness E. Agitation and restlessness

Correct Answer is ["A","B","D"]

Explanation

Choice A Reason:

Slowed psychomotor activity.

Slowed psychomotor activity is a hallmark of hypoactive delirium. Patients with this type of delirium often exhibit reduced physical movement and slower reaction times. This symptom can make hypoactive delirium more challenging to recognize compared to the more obvious agitation seen in hyperactive delirium.

Choice B Reason:

Impaired attention and concentration.

Impaired attention and concentration are common in all forms of delirium, including hypoactive delirium. Patients may have difficulty focusing, sustaining, or shifting attention, which can significantly impact their ability to engage in daily activities or follow conversations.

Choice C Reason:

Hallucinations and delusions.

While hallucinations and delusions can occur in delirium, they are more commonly associated with hyperactive delirium. Hypoactive delirium is characterized more by withdrawal and decreased responsiveness rather than the presence of hallucinations or delusions.

Choice D Reason:

Decreased alertness or responsiveness.

Decreased alertness or responsiveness is a key feature of hypoactive delirium. Patients may appear drowsy, lethargic, or less responsive to their environment. This can sometimes be mistaken for depression or fatigue, making it crucial to differentiate hypoactive delirium from other conditions.

Choice E Reason:

Agitation and restlessness.

Agitation and restlessness are characteristic of hyperactive delirium, not hypoactive delirium5. In hypoactive delirium, patients are more likely to be withdrawn and less responsive rather than agitated or restless.

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The nurse notices a client wandering in the hospital hall giggling, with bizarre behavior that is annoying and frightening other clients. A priority in caring for her is to:

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Correct Answer is D

Explanation

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Explanation

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