While walking down the hallway, the nurse finds a female client yelling, swinging her hands, and pushing a male visitor away from her hospital bed. Which intervention should the nurse implement first?
Determine who is assigned the care of the client.
Enter the room and quietly observe the interaction.
Notify the hospital security department immediately.
Instruct the visitor to leave the room immediately.
The Correct Answer is D
Choice A rationale: The nurse does not need to determine who is assigned the care of the client, as this is not relevant to the immediate situation.
Choice B rationale: The nurse should not enter the room and quietly observe the interaction, as this would delay the intervention and put the client and the visitor at risk.
Choice C rationale: The nurse should not notify the hospital security department immediately, as this would also delay the intervention and may escalate the situation.
Choice D rationale: The nurse should prioritize the safety of the client and the visitor, and intervene to stop the potential violence. The nurse should instruct the visitor to leave the room immediately, and then assess the client's condition and provide appropriate care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: The nurse does not need to determine who is assigned the care of the client, as this is not relevant to the immediate situation.
Choice B rationale: The nurse should not enter the room and quietly observe the interaction, as this would delay the intervention and put the client and the visitor at risk.
Choice C rationale: The nurse should not notify the hospital security department immediately, as this would also delay the intervention and may escalate the situation.
Choice D rationale: The nurse should prioritize the safety of the client and the visitor, and intervene to stop the potential violence. The nurse should instruct the visitor to leave the room immediately, and then assess the client's condition and provide appropriate care.
Correct Answer is B
Explanation
Choice A rationale: A client with combined partial and full-thickness burns on the anterior chest with a decreased O2 saturation is likely in need of critical care and should not be transferred to a general unit.
Choice B rationale: A client with nephrotic syndrome and mild edema is the most stable and has the least risk of complications among the four options.
Choice C rationale: The client with thyroidectomy has a risk of bleeding and needs frequent assessment of vital signs and dressing.
Choice D rationale: The client with renal transplant has a risk of rejection and infection and needs strict isolation and immunosuppressive therapy.
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