Which of the following interventions would a nurse use when caring for an inpatient client who expresses anger inappropriately?

Teach the client to avoid “I” statements related to the expression of feelings.

Tell the client to stop using a loud angry voice.

Use therapeutic touch to convey empathy.

Clearly explain the consequences of the behavior.

Answer and Explanation

The Correct Answer is D

Choice A Reason: Teach the client to avoid “I” statements related to the expression of feelings

Teaching a client to avoid “I” statements is not a recommended intervention. In fact, “I” statements are often encouraged in therapeutic settings because they help individuals express their feelings without blaming others. For example, saying “I feel angry when…” helps to communicate emotions constructively and can be a part of anger management strategies.

Choice B Reason: Tell the client to stop using a loud angry voice

While it might seem logical to ask a client to stop using a loud, angry voice, this approach can be counterproductive. It may escalate the situation by making the client feel unheard or invalidated. Instead, it is more effective to acknowledge the client’s feelings and then guide them towards expressing their anger in a more appropriate manner.

Choice C Reason: Use therapeutic touch to convey empathy

Therapeutic touch involves using physical touch to convey empathy and support. However, its effectiveness can vary depending on the client’s comfort with touch and cultural background. Some clients may find touch comforting, while others may find it intrusive or uncomfortable. Therefore, it is important to assess the client’s preferences and obtain consent before using therapeutic touch.

Choice D Reason: Clearly explain the consequences of the behavior

This is the correct answer. Clearly explaining the consequences of inappropriate behavior helps set boundaries and provides the client with an understanding of the impact of their actions. It is a crucial part of behavior management and helps the client learn appropriate ways to express their emotions. This approach is aligned with cognitive-behavioral strategies that focus on understanding the relationship between thoughts, feelings, and behaviors.

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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.

Correct Answer is ["600"]

Explanation

Step 1: Identify the total volume to be infused.

Total volume = 250 mL

Step 2: Identify the total time for infusion.

Total time = 25 minutes

Step 3: Calculate the rate in mL per minute.

Rate = Total volume ÷ Total time
Rate = 250 mL ÷ 25 minutes
Rate = 10 mL per minute

Step 4: Convert the rate to mL per hour.

Since there are 60 minutes in an hour, multiply the rate by 60.
Rate per hour = 10 mL per minute × 60
Rate per hour = 600 mL per hour

The nurse should program the pump to infuse at a rate of 600 mL per hour.

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Which of the following interventions would a nurse use when caring for an inpatient client who expresses anger inappropriately?

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Naxlex Comprehensive Predictor Exams

The nurse calculates that a patient must receive 1.3 mL of an anti-infective agent. The dose is ordered IM. Which of the following choices demonstrates safe, evidence-based practice?

Correct Answer is D

Explanation

A patient with fluid volume deficit must receive a 250 mL IV bolus of NS over 25 minutes via a peripherally inserted central line (PICC) on an IV pump. At what rate will the nurse program the pump? Round to the nearest whole number. Do not use trailing zeros.

Correct Answer is ["600"]

Explanation

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