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    ATI LPN Applied Skills Proctored Exam

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    Question: 1 of 44Ati Lpn Applied Skills Proctored Exam
    A nurse in a long-term care facility is caring for a client who is upset over not being able to find their spouse, who passed away years ago. Which of the following actions should the nurse take first?
    Explanation
    Rationale: A. Administer alprazolam is incorrect because medication is not the first intervention. Benzodiazepines may be used for severe anxiety but non-pharmacological approaches should be attempted first, especially in older adults where sedation and falls are concerns. B. Take the client for a walk outdoors and ask them to talk about their family is correct because it addresses the client’s emotional needs and promotes therapeutic communication and orientation. This action is a non-pharmacological intervention that helps the client cope with grief and confusion in a safe, supportive manner. According to the nursing process, addressing the client’s immediate emotional distress is the priority before using medications. C. Take the client to their room so they will not upset other clients is incorrect because it focuses on staff convenience rather than the client’s needs. Removing the client without addressing their emotional distress can increase anxiety, agitation, or feelings of isolation. D. Administer haloperidol is incorrect because antipsychotic medications are not indicated for normal grief or mild agitation unless the client is severely aggressive or psychotic. Using haloperidol as a first-line intervention is inappropriate and could cause adverse effects such as sedation, extrapyramidal symptoms, or falls.
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