When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?

Request backup from the staff.

Stand in the doorway.

Provide for personal space.

Encourage the client to sit down.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Requesting backup from the staff may be necessary if the situation escalates further, but it is not the initial action to take. Providing for personal space and attempting to de-escalate the situation should come first.

Choice B rationale:
Standing in the doorway may not be the most effective approach because it doesn't actively address the client's agitation or attempt to de-escalate the situation.

Choice C rationale:
Providing personal space is an important initial intervention when dealing with an agitated client. This approach helps maintain safety for both the nurse and the client and can reduce the perception of threat or intrusion.

Choice D rationale:
Encouraging the client to sit down may be a helpful de-escalation technique, but it should come after providing for personal space to ensure safety and reduce tension.

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Correct Answer is A

Explanation

Choice A rationale:
Teaching the client to develop a plan for daily structured activities is a key intervention for addressing major depressive disorder with symptoms like psychomotor retardation, hypersomnia, and motivation. Structured activities can help the client regain a sense of purpose, improve motivation, and gradually return to a normal level of functioning.

Choice B rationale:
Encouraging exercise is generally beneficial for mental health, but it may not be the most effective intervention for addressing the specific symptoms mentioned in this scenario.

Choice C rationale:
Suggesting the client develop a list of pleasurable activities is a valuable intervention but may not directly address the psychomotor retardation and hypersomnia seen in this case.

Choice D rationale:
Providing education on methods to enhance sleep is important, especially if hypersomnia is a symptom, but it should be part of a broader treatment plan that also includes addressing psychomotor retardation and motivation.

A. Cancer screening results, anger, gastritis, daily alcohol intake. B. Consumption, liver enzyme, gastrointestinal complaints, and bleeding. C. Efforts to cut down, annoyance with questions, guilt, and drinking as an "Eye-opener." D. Minimizes drinking, frequently misses family events, guilt about drinking, and amount of daily intake.

Correct Answer is C

Explanation

Choice A rationale:
This option includes various factors but does not directly align with the CAGE questions.

Choice B rationale:
While it mentions liver enzyme and gastrointestinal complaints, it does not specifically address the CAGE questions about efforts to cut down, annoyance with questions, guilt, or using alcohol as an "Eye-opener."

Choice C rationale:
The CAGE questionnaire is designed to assess for alcohol misuse or dependency. The responses in choice C ("Efforts to cut down," "annoyance with questions," "guilt," and "drinking as an 'Eye-opener'") are the key elements of the CAGE questionnaire that indicate potential issues with alcohol use. These responses should be explored further to assess the client's relationship with alcohol and the impact it may have on their life.

Choice D rationale:
This option mentions minimizing drinking and missing family events but does not cover all the key elements of the CAGE questionnaire.

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When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

Correct Answer is A

Explanation

The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?

Correct Answer is C

Explanation

The nurse is assessing a client whose spouse died of a stroke two weeks ago and who reports having numbness and tingling on the right side of the body. The nurse should consider the client's symptoms may likely be due to which condition.

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