Which of the following nursing intervention would least likely be effective when dealing with a client with aggressive behavior?

Correct Answer: C

Rationale: Maintaining eye contact (C) is least effective with aggressive clients; it can escalate tension, per de-escalation guidelines. Calm approach (A), expression (B), and isolation (D) soothe or manage behavior. Eye contact may provoke, making C incorrect.

Correct Answer: B

Rationale: BP 60/40 (B) is highest priority; severe hypotension threatens perfusion, per ABCs (circulation). Pain (A), fever (C), and cyanosis (D) are urgent but secondary to life-threatening shock. B demands immediate action, making it correct.

Correct Answer: D

Rationale: For Mr. Gary's chronic pain at 67, a standardized pain scale (D) best assesses intensity, per pain management standards (e.g., numeric scale). Observation (A) misses subjectivity, description (B) lacks precision, physical assessment (C) is secondary. Scales quantify chronic pain reliably, especially in older adults, making D the optimal choice.

Correct Answer: A

Rationale: The client can leave anytime, even against medical advice (A), per autonomy in the bill of rights AMA discharge is legal. No right to refuse (B) is false, hospitals can't deny emergencies (C) per EMTALA, considerate care isn't nurse-only (D). A upholds patient choice, making it true.

Correct Answer: A

Rationale: Body to morgue within 1 hour (A) isn't true no strict universal timing, per facility policy. Hand washing (B), tube removal (C), and closing eyes/mouth (D) are standard. A's rigidity misaligns with flexible care, making it untrue.