A nurse is caring for a client following a suicide attempt.
The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority?

Choice A rationale: A client with Obsessive Compulsive Disorder (OCD) who insists on mopping the floor in the day room does not pose a direct threat to themselves or others. OCD is characterized by obsessions (persistent, intrusive

thoughts) and compulsions (repetitive behaviors that the person feels compelled to perform). The act of mopping the floor could be a compulsion for this client. While it may be disruptive or unusual, it is not harmful. Therefore, restraints would not be appropriate in this situation.

Choice B rationale: A client with a personality disorder who tries to manipulate staff to gain privileges can be challenging to manage, but this behavior does not warrant the use of restraints. Personality disorders are characterized by enduring patterns of behavior, cognition, and inner experience that deviate from the expectations of the individual’s culture. These patterns are inflexible and pervasive across many personal and social situations.

While manipulation can be frustrating for staff, it is not a danger to the client or others, and other interventions should be used to manage this behavior.

Choice C rationale: A client with Bulimia Nervosa who refuses to come to the dining room for meals is exhibiting behavior related to their eating disorder, but this does not justify the use of restraints. Bulimia Nervosa is characterized by recurrent episodes of binge eating followed by compensatory behaviors such as vomiting, fasting, or excessive exercise. Refusal to eat in a communal setting like a dining room is not uncommon for individuals with eating disorders. This behavior should be addressed through therapeutic interventions, not restraints.

Choice D rationale: A client who is just recovering from a benzodiazepine overdose is the correct answer. Restraints are contraindicated for this client because they could cause physical harm. After a benzodiazepine overdose, the client may experience symptoms such as drowsiness, confusion, and impaired coordination. Restraints could increase the risk of injury, particularly if the client becomes agitated or tries to remove them. In addition, restraints could potentially interfere with medical treatment for the overdose.

Choice A rationale:

This response is dismissive and judgmental. It implies that the client's partner was wrong to share the news, and it does not acknowledge the client's feelings. This could make the client feel even more isolated and unsupported.

It's important to remember that the client is likely experiencing a range of emotions, including shock, sadness, anger, and anxiety. The nurse's role is to provide support and validation, not to judge the client's feelings or the actions of their partner.

Choice B rationale:

This response demonstrates empathy and understanding. It acknowledges the client's feelings and invites them to share more about their experience. This can help the client to feel heard and supported.

By verbalizing the client's feelings, the nurse is helping them to process the news and begin to cope with the situation. This can be a valuable first step in helping the client to develop a plan for moving forward.

Choice C rationale:

This response is dismissive and unhelpful. It does not acknowledge the client's feelings, and it offers no support or guidance. This could make the client feel even more hopeless and helpless.

While it may be true that there is not much the client can do about the situation immediately, the nurse can still offer support and help the client to explore their options.

Choice D rationale:

This response is premature and potentially unrealistic. The client may not be ready to contact their boss yet, and there is no guarantee that their job will be available to them. This could set the client up for disappointment and further distress.

It's important to allow the client to process the news and consider their options before taking any action. The nurse can help the client to identify potential resources and supports, and to develop a plan that is right for them.