A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse:
Answer(s): A
(A) This answer is correct. Least restrictive measures should always be attempted before a client is placed in seclusion or restraints. The nurse should first try a calm verbal approach, suggest a quiet room, or request that the client take "time-out" before placing the client in seclusion, givingmedication as necessary, or restraining. (B) This answer is incorrect. A calm verbal approach or requesting that a client go to his room should be attempted before restraining. (C) This answer is incorrect. Restraints should be applied only after all other measures fail to control the behavior. (D) This answer is incorrect. Other clients should be removed from the area. It is often very anxiety producing for other clients to see a peer out of control. It could also lead to mass acting- out behaviors.
A 19-year-old male client arrived via ambulance to the emergency room following a motorcycle accident. He is comatose. His face has evidence of dried blood. On assessment, the nurse notes an obvious injury to his left eye. The preferred positioning for a client with an obvious eye injury is:
Answer(s): D
(A) A reclining position can cause a penetrating object to advance further into the eye. (B) Prevention of further injury is the priority, not comfort. (C) A side-lying position may increase intraocular and intracranial pressure if an accompanying head injury is suspected. (D) A sitting position with the head supported will prevent further injury while allowing injury care to take place.
Post your Comments and Discuss NCLEX NCLEX-RN exam with other Community members:
Naveen Ahlam Commented on January 18, 2025 Great stuff Anonymous
Om Commented on December 31, 2024 Good question Anonymous
Isadora Guimarães Commented on December 30, 2024 Very good to study UNITED STATES
Marydee Commented on April 02, 2020 Just purchased, will see if it is the real deal. Will give a further update later! Anonymous
Our website is free, but we have to fight against bots and content theft. We're sorry for the inconvenience caused by these security measures. You can access the rest of the NCLEX-RN content, but please register or login to continue.