A nurse in a long-term care facility is monitoring clients in the day room. A client who has dementia becomes angry and starts screaming at the nurse. Which of the following interventions should the nurse take first?
Place the client in a seclusion room.
Engage the client in a repetitive activity as a distraction.
Administer PRN haloperidol IM to the client.
Apply wrist restraints to the client.
The Correct Answer is B
A. Seclusion is a highly restrictive intervention and is not the first action for managing agitation in dementia clients.
B. Engaging the client in a repetitive activity as a distraction is the least restrictive intervention and can help calm the client by redirecting their attention. Non-pharmacological and less restrictive approaches are preferred as initial responses to manage agitation in dementia clients.
C. Administering PRN haloperidol IM is a pharmacological intervention and should be reserved for situations where less restrictive measures have failed.
D. Applying wrist restraints is a restrictive intervention that can increase agitation and is not appropriate as a first-line approach.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is B
Explanation
A. While the provider may need to countersign the prescription, this does not affect the accuracy of the order at the time of receiving it.
B. Verifying the medication name along with its intended purpose helps ensure clarity and reduces the risk of medication errors, especially during telephone orders where miscommunication is more likely.
C. Verbalizing "B-I-D" rather than "twice per day" could cause confusion; clear language is essential, and "twice per day" is more understandable.
D. Using the generic name rather than the trade name is recommended to avoid confusion with similar brand names.
Correct Answer is C
Explanation
A. Placing a midstream urine sample in a specimen refrigerator is an appropriate practice and does not pose an infection control hazard.
B. Wiping a countertop with chlorhexidine solution is a correct practice following a blood spill and contributes to infection control.
C. Pouring sterile 0.9% sodium chloride irrigation solution directly onto an open pressure wound before collecting a specimen poses an infection control hazard, as it can introduce contaminants to the wound and affect the culture results.
D. Using alcohol-based antiseptic to clean hands after interacting with a client who has varicella zoster is an appropriate infection control measure and reduces the risk of spreading infection.