A client is noted to have a high level of non-goal-directed motor activity, running from chair to chair
in the solarium. He is wide eyed and seems terror stricken.
He cries "They're coming! They're
coming!" He neither follows staff direction nor responds to verbal efforts to calm him. The initial
nursing intervention of highest priority is to
a. provide for client safety.
b. increase environmental stimuli.
c. respect the client's personal space.
d. encourage clarification of feelings.
ANS: A
Safety is of highest priority because the client experiencing panic is at high risk for self-injury
related to increased non-goal-directed motor activity, distorted perceptions, and disordered thoughts.
Option B: The goal should be to decrease environmental stimuli. Option C is a lower priority than
safety. Option D: Clarification of feelings cannot take place until the level of anxiety is lowered.
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Calculate the volume to be administered IV push and determine if it is a safe dosage. _______________ a. 0.5 mL b. 2.5 mL c. 2 mL d. Hold and clarify orderâ€"overdose
When evaluating a woman for sexually transmitted infections (STIs), the nurse should be aware that the most common bacterial sexually transmitted infection is:
a. Gonorrhea. b. Syphilis. c. Chlamydia. d. Candidiasis.
A patient's potassium and calcium levels are below the normal range. The nurse should check for a decreased level of which other electrolyte?
1. Phosphorous 2. Sodium 3. Magnesium 4. Chloride
The client with chronic obstructive pulmonary disease (COPD) has had a sample for a serum theophylline level drawn as part of routine follow-up care
Which of the following results would lead the nurse to conclude that the client has most likely been compliant with medication thera-py? 1. 3 mcg/mL 2. 7 mcg/mL 3. 14 mcg/mL 4. 24 mcg/mL