mental health

A schizophrenic client who is taking fluphenazine decanoate is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse about a planned vacation and will return in 18 days. Which statement by the client indicates to the nurse a need for health teaching? A. "I am going to have lots of fun at the beach and plenty of time in the sun." B. "While I am on vacation, I will not eat or drink anything that contains alcohol." C. "I will notify the health care provider if I have a sore throat or flulike symptoms." D. "I will continue to take my benztropine mesylate every day." Submit

A Rationale:Photosensitivity is a side effect of fluphenazine decanoate, so the client should be instructed to avoid the sun. Options B, C, and D indicate accurate knowledge. Alcohol acts synergistically with fluphenazine decanoate. A sore throat and flulike symptoms are signs of agranulocytosis, which is also a side effect of Prolixin. To avoid extrapyramidal symptoms (EPS), anticholinergic drugs, such as Cogentin, are often prescribed prophylactically with fluphenazine decanoate.

A client on the behavioral health states, "I hear angles singing. They are calling me home." What is the nurse's best statement in response to this hallucination? A. "Are you thinking of hurting yourself so you can join the angles?" B. "I do not hear angles. It is mealtime; please take a seat at the table." C. "Where are the angles that you hear singing?" D. "While you hear angles, I do not hear anything."

A Rationale:The primary nursing responsibility is to keep the client safe from self-harm. Do not attempt to correct the client who is having hallucinations, nor should the nurse play into the hallucination. The priority is safety, then the nurse can help the client orient to reality.

The nurse is caring for a client who is taking valproic acid. Which laboratory finding is most important to include in this client's record? A. Liver function test results B. Creatinine clearance C. Complete blood count D. Chemistry panel Submit

A Rationale:Valproic acid is metabolized by the liver and can cause hepatotoxicity, so laboratory findings of liver function tests should be included in the client's record. Option B should be in the client record of those who are receiving lithium because it is excreted by the kidneys. Options C and D are routine laboratory tests and are not specifically related to administration of valproic acid.

The emergency department nurse is concerned a client may develop signs of alcohol withdrawal. What assessments will the nurse include when providing care to this client? (Select all that apply.) A. Anxiety B. Hypotension C. Tachycardia D. Difficult to arouse E. Irritability F. Tremors

A C E F Rationale:The client will demonstrate hypertension and hyperalertness. The remaining symptoms are associated with alcohol withdrawal. Additional symptoms include anorexia, anxiety, easily startled, insomnia, jerky movements, and possibility of seizures 7 to 48 hours after consumption of the last drink.

The nurse is talking to a client with heightened anxiety. What actions will the nurse include when providing care for this client? (Select all that apply.) A. Ask, "Do you have any idea what happened to increase your anxiety level?" B. Encourage the client to play an individual player card game, like solitaire. C. Have the client work with others in the kitchen to prepare an afternoon snack. D. Have the client review recent events that may have triggered the change. E. State, "Tell me what you are thinking and feeling now."

A,D,E Rationale:The nurse must attempt to solicit the preceding events and feelings prior to the increase in anxiety. Playing solitaire does not include any therapeutic actions by the nurse. Having the client work with others may trigger even more anxiety, especially if the root of the anxiety is one of the others in the kitchen.

The nurse is working with family members of a client with advanced Alzheimer's disease. What client behaviors will the nurse include in the discussion with the family? (Select all that apply.) A. Difficulty walking independently B. Inability to eat independently C. Switching days and nights D. Bowel and urinary incontinence E. Unaware if surroundings

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The nurse is providing instructions for disulfiram therapy. Which client statement indicates an understanding of the instructions? A. I can drink alcohol up to 4 hours before I start the therapy. B. I will not drink alcohol during and after the therapy. C. If I drink alcohol with the therapy I will break out in a rash. D. After I complete the therapy, I will no longer be an alcoholic. Submit

B Rationale:Alcohol consumption during and up to 14 days after therapy can cause a disulfiram-alcohol reaction which includes headache, flushing, shortness of breath, nausea, vomiting, dizziness, tiredness, fainting, irregular tachycardia, and blurry vision. No alcohol should be consumed for up to 12 hours before initiating therapy. The client will always be an alcoholic, whether recovering or not.

The nurse is providing care to a client with Alzheimer's disease. Which actions will the nurse include in the client's plan of care? (Select all that apply.) A. Finish buttoning the client's shirt when there are 2 buttons remaining opened. B. Place a picture of the client's family on the bedroom door. C. Walk with the client for 15 minutes at the same time every day. D. Do all activities of daily living for the client. E. Place the client in a darkened room for 2 hours every day. Submit

B C Rationale:The nurse needs to assist the client in maintaining independence. Finish buttoning the client's shirt does not allow the client time to finish a task. The client needs activities that occupy and distract; a darkened room does not accomplish this goal. Provide the client with familiar surroundings and help the client establish a healthy routine.

The emergency department nurse assesses a new client and finds constricted pupils, drowsiness, impaired memory, and slurred speech. Which vital sign would be most concerning to the nurse? A. B/P 108/64 mm Hg B. Temperature 99°F/37.2°C C. Respirations 10 breaths/min D. Pulse 64 beats/min

C Rationale:The client is demonstrating signs of opioid intoxication. Depression of the respiratory center is most concerning for this client. Blood pressure and pulse can also run low with opioid intoxication. The temperature is mildly elevated.

A 22-year-old client is admitted to the psychiatric unit from the medical unit following a suicide attempt with an overdose of diazepam. When developing the nursing care plan for this client, which action would be most important for the nurse to include? A. Assist client to focus on personal strengths. B. Set limits on self-defacing comments. C. Remind the client of daily activities in the milieu. D. Assist the client to identify why he or she was self-destructive.

Correct Answer: A Rationale:Encouraging the client to focus on his or her strengths helps the client become aware of positive qualities, assists in improving self-image, and aids in coping with past and present situations. Although nursing actions should assist the client in decreasing self-defacing comments and informing the client of daily activities in the milieu, these interventions are not priorities at this time. Option D is not as important as assisting the client to overcome the depression, which resulted in the overdose, and asking "why" is not therapeutic.

A client begins taking an atypical antipsychotic medication. The nurse must provide informed consent and education about common medication side effects. Which client education will be most important? A. Maintain a balanced diet and adequate exercise. B. Be sure that the diet is adequate in salt intake. C. Monitor for any changes in sleep pattern. D. Report any unusual facial movements.

Correct Answer: A Rationale:Several atypical antipsychotic medications can cause significant weight gain, so the client should be advised to maintain a balanced diet and adequate exercise. Option B is important with lithium, a mood stabilizer. Options C and D are less common than weight gain.

The nurse is conducting an intake interview for a new client. The client states, "My spouse was just diagnosed with pancreatic cancer. I do not know what to do." The client's plan of care will reflect which type of crisis? A. Situational B. Emotional C. Adventitious D. Maturational

Correct Answer: A Rationale:There are three generally acceptable types of crisis. Situational crisis involves an unanticipated external source such as loss of a job, divorce, serious illness or death. An adventitious crisis often involves a disaster or is an event that is not a part of everyday life, such as flood, earthquake, fire, war, or murder. A maturational crisis includes role changes in life such as marriage or the birth of a child.

For the client with an altered thought process, what will the nurse include in the client's plan of care? (Select all that apply.) A. Place items from home in the client's room. B. Place a calendar on the wall across from the client's bed. C. Place a clock on the client's bedside table. D. Establish a different waking pattern every day. E. Call the client by a new name, "Sweetie Pie."

Correct Answer: A,B,C Rationale:For those with an altered thought process, routine and patterns are familiar and need to be encouraged. Call the client by name, not an unfamiliar nickname, as the client may not realize who the nurse is talking to. The remaining actions help with orientation.

One of the clients on the behavioral health unit states, "I am the savior and I am here to take all of you to heaven with me." What statements will the nurse include in this client's plan of care? (Select all that apply.) A. "Please describe what you are seeing now." B. "Tell me what you are feeling at this moment." C. "You can't be the savior. Now come with me to the dayroom." D. "You see yourself as the savior. I see you as my client." E. "You can be the savior for the next 30 seconds, then move on."

Correct Answer: A,B,D Rationale:The role of the nurse is not to argue with the client and convince the client that the delusions are false. Setting time limits on the client's delusional statements can be helpful, but 30 seconds is a short period of time. The nurse can help the client describe the delusion and focus on the feelings during the delusion.

The nurse is assigned to a client admitted with paranoia. Which assessments will the nurse include in the client's plan of care? (Select all that apply.) A. Suspiciousness B. Distrusting C. Boredom D. Argumentative E. Grandiosity

Correct Answer: A,B,D,E Rationale:In addition to the behaviors listed, those with paranoia may also exhibit hostility, aloofness, rigidity in thinking, controlling of other and critical of others.

A woman brings her 48-year-old husband to the outpatient psychiatric unit and tells the nurse that he is being treated for dissociative disorder. Which data are consistent with this diagnosis? (Select all that apply.) A. Sleepwalking B. Unable to remember who he is C. Has recurrent intrusive obsessions D. Acute attack of anxiety E. Exhibits multiple personalities

Correct Answer: A,B,E Rationale:Sleepwalking, amnesia, and multiple personalities are examples of detaching emotional conflict from one's consciousness and are consistent with a diagnosis of dissociative disorder (A, B, E). (C) is consistent with obsessive-compulsive disorder. (D) is associated with neuro-cognitive disorders.

Which actions will the nurse take for the client in a depressive phase? (Select all that apply.) A. Ask the client, "Are you thinking of harming yourself?" B. Encourage the client to take part in a game of dodgeball. C. Have the client sit in the day area and fill cups with bird feed. D. Encourage the client to take frequent rest periods. E. Stay with the client when performing daily hygiene and mouth care.

Correct Answer: A,C,D,E Rationale:The client in a depressive phase has little energy, and needs constant prompting and reassurance. A game of dodgeball uses too much of the client's energy and competitive games need to be avoided. It is important to know if the client wishes self-harm. Filling cups with bird feed is a low energy but satisfying task. Resting is important for those in a depressive phase. The client may not take the usual care in personal hygiene and need the assistance of the nurse to accomplish those tasks.

The nurse is assigned to a client admitted with paranoia. Which actions will the nurse include in the client's plan of care? (Select all that apply.) A. Assess for suicide risk. B. Offer lots of hugs to reassure the client. C. Plan to care for the client when on duty. D. Whisper in the presence of the client. E. Provide a nonthreatening environment.

Correct Answer: A,C,E Rationale:Limit physical contact and do not whisper around the client. This client is at risk for self-harm. Continuity of care is important for the paranoid client. A nonthreatening environment helps establish trust.

Which topics should the nurse include in an education program for clients with schizophrenia and their families? (Select all that apply.) A. Importance of adherence to medication regimen B. Current treatment measures for substance abuse C. Signs and symptoms of an exacerbation D. Prevention of criminal activity E. Behavior modification for aggression F. Chronic grief associated with long-term illness

Correct Answer: A,C,F Rationale:Medication adherence is an important component of successful rehabilitation (A). Clients and their families also need to know the signs and symptoms of an exacerbation or relapse of the disease (C), which is frequently associated with poor medication compliance. Acknowledging the chronic sorrow associated with severe and persistent mental illness (F) helps individuals negotiate the grieving process. (B, D, and E) are not universal problems associated with schizophrenia.

Which actions will the nurse take for the client admitted with mania? (Select all that apply.) A. Assign the client to a private room. B. Have the client to play a card game with others on the unit. C. Include the client in preparation of a solitary afternoon craft. D. Assist the client with sweeping the floor of the unit. E. Provide the client with a chicken leg and carrot sticks.

Correct Answer: A,D,E Rationale:The client with mania has energy and it needs to be used in a productive manner. A card game is likely to produce a disruption with others on the unit. The client has significant energy and a craft is not likely to use enough of the client's energy. A private room will decrease the interruptions to the roommate. Use the energy of the client in productive activities. The nutritional needs of the client with mania need to be met with hand-held nutritious foods.

A client who is being treated with lithium carbonate for manic depression begins to develop diarrhea, vomiting, and drowsiness. Which action should the nurse take first? A. Notify the health care provider immediately and force fluids. B. Prior to giving the next dose, notify the health care provider of these symptoms. C. Record the symptoms and continue with medication as prescribed. D. Hold the medication and refuse to administer additional doses.

Correct Answer: B Rationale:Although these are expected symptoms, the health care provider should be notified prior to the next administration of the drug. Early side effects of lithium carbonate (occurring with serum lithium levels below 2 mEq/L) generally follow a progressive pattern, beginning with diarrhea, vomiting, drowsiness, and muscular weakness (option C). At higher levels, ataxia, tinnitus, blurred vision, and large dilute urine output may occur. Option A will lower the lithium level. Option D is not warranted.

A middle-aged adult was discharged from a treatment center 6 weeks ago following treatment for suicide ideation and alcohol abuse. In a follow-up visit to the mental health clinic, the client complains of lethargy, apathy, irritability, and anxiety. Which question is most important for the nurse to ask? A. "Are you taking prescribed antidepressants?" B. "How much alcohol do you consume daily?" C. "What seems to precipitate the anxious feelings?" D. "How many hours do you sleep per day?"

Correct Answer: B Rationale:First, and most importantly, the client's use of alcohol should be determined because further treatment is dependent on the client's sobriety, and asking how much alcohol is being consumed is a better question than asking if the client is drinking, which is a "yes-no" answer that does not promote dialogue. Options A, C, and D provide worthwhile assessment data, but first the nurse should determine if the client is still drinking because all efforts to treat symptoms associated with depression are diminished if the client is still consuming alcohol.

Clients are preparing to leave the mental health unit for an outdoor smoke break. A client on constant observation cannot leave and becomes agitated and demands to smoke a cigarette. Which action should the nurse take first? A. Remind the client to wear the nicotine patch. B. Determine if the client still needs constant observation. C. Encourage the client to attend the smoking cessation group. D. Explain that clients on constant observation cannot smoke.

Correct Answer: B Rationale:The nurse should continually reassess the need for constant observation so that the client can have unit privileges such as outdoor breaks. Options A and C do not meet the client's need and desire to smoke. Option D will cause more agitation.

A client in an acute care facility has been taking antipsychotic medications for the past 3 days with a decrease in psychotic behaviors and no adverse reactions. On the fourth day, the client experiences an increase in blood pressure and temperature and demonstrates muscular rigidity. Which action should the nurse initiate? A. Place the client on seizure precautions and monitor frequently. B. Take the client's vital signs and notify the health care provider immediately. C. Describe the symptoms to the charge nurse and document them in the client's record. D. No action is required at this time because these are known side effects of the medications.

Correct Answer: B Rationale:This is an emergency situation, and the client requires immediate management in a critical care setting. These symptoms are descriptive of neuroleptic malignant syndrome (NMS), an extremely serious and life-threatening reaction to neuroleptic drugs. The major symptoms of this syndrome are fever, rigidity, autonomic instability, and encephalopathy. Respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure can result in death. Option A is not indicated in this situation. Option C does not consider the seriousness of the situation. Option D is an incorrect statement.

The nurse is performing in-service training on bullying to a group of elementary school teachers. The nurse indicates that the teachers must be alert to the signs a child is being bullied. What signs will the nurse share with the teachers? (Select all that apply.) A. Retaliation B. Low self-esteem C. Depression D. Social withdrawal E. Incoordination

Correct Answer: B,C,D Rationale:The bullied child regresses inwardly and retaliation is often not observed. Incoordination is not a sign of bulling. The remaining are signs of bulling.

The nurse is planning care for a client in the depressed phase of bipolar disorder. What foods will the nurse include in the client's plan of care? (Select all that apply.) A. A chocolate and caramel candy bar B. Celery filled with peanut butter C. A mixture of nuts and dried fruit D. Greek yogurt with mixed berries and granola E. Dried "O" shaped wheat cereal without milk

Correct Answer: B,C,D Rationale:The goal is to offer small, high calorie and high protein nutritional foods throughout the day. The depressed client will often feel like not eating. Hand-held foods could be less intimidating to eat in lieu of a large meal. A chocolate caramel candy bar is filled with empty calories. "O" shaped cereal has carbohydrates but little protein.

The nurse manager is working with architects and child abduction specialists to design a state-of-the-art maternal-infant care unit. What safety features will the nurse manager request of the design team? (Select all that apply.) A. Make all rooms semiprivate rooms. B. Design the nurse's station so all exits are visible. C. Install an infant security monitoring system with sensor infant bands. D. Require all access points to the unit are monitored by a security camera. E. All doors must have electronic locks that can only be opened by approved personnel.

Correct Answer: B,C,D,E Rationale:Private rooms offer the best security as it decreases the visitor traffic to only those known to the client. All security measures are to help prevent newborn abduction. Additionally, place matching bands on both parents, or close family relative (like the client's mother) and check to make sure the infant is transported only by hospital personnel or appropriately banded family.

The nurse observes a newly admitted client stepping in and out of the dayroom multiple times. The client repeatedly states during the observed behavior, "I must not step on the crack between the hall and the dayroom." What are the nurse's next actions? (Select all that apply.) A. Tell the client, "Stop that behavior and go watch TV!" B. Ask the client, "What were you thinking right before you stepped into the dayroom?" C. Provide the client with a protein bar and milkshake. D. State, "I see you repeatedly stepping in an out of the dayroom." E. Quietly ask the client, "Please come and sit with me so we can talk about your feelings."

Correct Answer: B,C,D,E Rationale:The nurse must provide a trusting and compassionate environment that provides for client safety. Telling the client to stop the behavior does nothing to address the concerns that precipitate the behavior and does not involve the nurse. The client's physical needs must be met during the initial phase of treatment. The client may not be able to initial stop the behavior, so providing hand-held nutritious foods will support the physical needs. The remaining statements acknowledge the client's behaviors and offer support during the ritualistic behaviors.

What instructions should the nurse include in the discharge teaching plan of a client who has recently been prescribed oxazepam? (Select all that apply.) A. Take the medication in the morning for best results. B. Do not combine this medication with alcohol. C. This medication is typically used for short-term treatment. D. Stop the drug immediately if sleepiness occurs. E. Avoid driving or operating equipment while taking this drug.

Correct Answer: B,C,E Rationale:Harm can occur if oxazepam is taken with alcohol or other central nervous system (CNS) depressants (B). Oxazepam is a benzodiazepine used for the short-term treatment of anxiety (C). Sleepiness is an expected side effect; therefore, driving or operating equipment should be avoided (E). The drug should be taken in the evening because of sedation effects (A) and should be tapered, not immediately stopped, because of withdrawal effects (D). oxazepam is an antianxiety med also for alcohol abuse treatment

The nurse observes a client with Alzheimer's disease wandering. What actions will the nurse take for this client? (Select all that apply.) A. Tell the client, "It is time for sleep." B. Secure all doors to stairwells and outdoors. C. Walk with the client. D. Remind the client it is 2:00 am. E. Provide the client a clear path.

Correct Answer: B,C,E Rationale:Wandering is common for those with Alzheimer's. The nurse must provide a safe environment and prevent unsafe wandering. Those with Alzheimer's often get their nights and days mixed up so reminding them of the time is not useful to them. As long as the client is closely supervised and safe, there is no reason to prohibit the client from wandering.

The clinic nurse notes bruises in various stages of healing on the client's back and legs. What questions must the nurse include in the client's assessment? (Select all that apply.) A. "Those bruises are shocking! What happened to you?" B. "Is anyone hurting your back and legs?" C. "I see you have lots of bruises. Are you very clumsy?" D. "When you and your spouse disagree, what happens to you?" E. "Has your spouse ever threatened you verbally or with violence?"

Correct Answer: B,D,E Rationale:Developing trust in providing a calm, nonjudgmental approach is essential when working with suspected abuse victims. By stating, "Those bruises are shocking" is alarmist, and does not place the client at ease. Asking if the client is clumsy give the client a way to not identify if abuse is occurring. The remaining questions are appropriate to assess for physical abuse.

The nurse on the behavioral health unit is concerned a new admission will develop withdrawal delirium. During which timeframe will the nurse pay particular attention to this client? A. 1 to 12 hours after last consumption B. 12 to 18 hours after last consumption C. 18 to 48 hours after last consumption D. 48 to 72 hours after last consumption

Correct Answer: D Rationale:Withdrawal delirium is a medical emergency that can include client death after a myocardial infarction, vascular collapse, aspiration, embolism, and electrolyte imbalance. The height of occurrence appears 48 to 72 hours after last consumption.

6-year-old learns of the recent death of a grandparent. The child and grandparent spent weekends together for the past four years. The parent notes the child has difficulty concentrating and seeks the advice of a healthcare provider. What will the nurse include in the parent's teaching plan? (Select all that apply.) A. Promote activities that the child enjoys. B. Encourage the child to express feelings through coloring. C. Answer the child's questions honestly. D. Make an appointment with a child psychologist. E. Hold and cuddle the child to reinforce closeness.

Correct | Correct Answer: A,B,C,E Rationale:A child at this age can realize that death is permanent. The child may find it difficult to concentrate and may even feel responsible for the death. Help the child through this time with pleasurable outlets and activities. There is no need for a child psychologist at this time. The change in behavior is anticipated.

Which activities will the nurse include in the care plan for the client admitted with depression? (Select all that apply.) A. Coloring alone in the dayroom B. Low aerobic exercise class with others C. Walking the unit with an aide D. Watching a movie with others E. Making snack mix with one other client

Correct | Correct Answer: B,C,E Rationale:The goal is to get the depressed client to use some energy in a positive way, without overwhelming the client. Coloring alone is a low energy, solitary activity. While this may be preferred by the client, it does nothing to slowly engage the client with others. Watching a movie is generally a quiet action. Engaging in discussion afterward may help the client, but that is not a stated option. Making snack mix is nonthreatening and engages the client with one other on the unit. This activity slowly engages the client.

he nurse is reviewing a treatment plan with a client who just attempted suicide. Which client statement is most reassuring to the nurse? A. "I will let you know when I am feeling that I want to harm myself again." B. "My family is so important to me and I will focus on them." C. "I have signed the contract that I will not hurt myself again." D. "Trying to kill myself was a selfish gesture on my part."

Correct | Correct Answer: C Rationale:The client must agree to the treatment plan. Signing a contract has a greater rate of compliance than a verbal contract. Reflecting on family and actions are useful, but the written agreement is more powerful.

On admission, a highly anxious client is described as delusional. Delusions are most likely to occur with which disorders? A. Dissociative disorders B. Personality disorders C. Anxiety disorders D. Psychotic disorders

D Rationale:Delusions are false beliefs characteristic of psychosis. Delusions are generally not characteristic of options A, B, and C.

A 35-year-old client admitted to the psychiatric unit of an acute care hospital tells the nurse of poisoning attempts. The client's delusions are most likely related to which factor? A. Authority issues in childhood B. Anger about being hospitalized C. Low self-esteem D. Phobia of food

Rationale:Delusional clients have difficulty with trust and have low self-esteem. Nursing care should be directed at building trust and promoting positive self-esteem. Activities with limited concentration and no competition should be encouraged to build self-esteem. Options A, B, and D are not specifically related to the development of delusions.

A 38-year-old client is admitted with a diagnosis of paranoid schizophrenia. When the lunch tray is brought to the room, the client refuses to eat and tells the nurse, "I know you are trying to poison me with that food." Which response by the nurse is the most therapeutic? A. "I'll leave your tray here. I am available if you need anything else." B. "You're not being poisoned. Why do you think someone is trying to poison you?" C. "No one on this unit has ever died from poisoning. You're safe here." D. "I will talk to your health care provider about the possibility of changing your diet."

Rationale:Option A is the best choice because the nurse does not argue with the client or demand that the client eat but offers support by agreeing to be there if needed, which provides an open, rather than closed, response to the client's statement. Options B and C are challenging the client's delusions, and option B asks "why." Probing questions, which start with "why," are usually not therapeutic communication for a psychotic client. Option D has not addressed the actual problem—that is, the client's delusions.

25-year-old client has been particularly restless, and the nurse finds the client trying to leave the psychiatric unit. The client tells the nurse, "Please let me go! I must leave because the secret police are after me." What is the nurse's best response? A. "No one is after you. You're safe here." B. "You'll feel better after you have rested." C. "I know you must feel lonely and frightened." D. "Come with me to your room, and I will sit with you."

Rationale:Option D is the best response because it offers support without judgment or demands. Option A is challenging the client's delusion. Option B is offering false reassurance. Option C is a violation of therapeutic communication because the nurse is telling the client how she or he feels (frightened and lonely), rather than allowing the client to describe his or her own feelings. Hallucinating and delusional clients are not capable of discussing their feelings, particularly when they perceive a crisis.

The nurse encounters a client with bipolar disorder in an aggressive state. What is the priority nursing action for this client? A. State to the client, "You need to settle down now!" B. Say, "If you throw that lamp you will need to stay in your room for 1 hour." C. Call an alert to summon security and prepare a sedative. D. Place the client in a restraint vest and in a quiet room. Submit

Rationale:The nurse needs to indicate to the client the consequences of aggressive behavior. Stating you need to settle down is nontherapeutic for the aggressive client. Calling security can precipitate more agitation. A restraint vest and a quiet room is a last resort for the aggressive client and should be used only when the client is at risk for harm to self or others. There is no indication in the stem that there is a risk for harm, only aggression.