A nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unit. Which of the following actions should the nurse take first?
Explain the client that the behavior was unacceptable.
Explore the truth of the client's statements.
Set behavioral limits for the client.
Establish a client relationship
The Correct Answer is C
A. Explain to the client that the behavior was unacceptable: While addressing the behavior is important, it is more effective to first establish clear limits and boundaries to prevent further incidents.
B. Explore the truth of the client’s statements: This step involves assessing the client's statements and understanding their perspective, which is important but can be done after setting behavioral limits.
C. Set behavioral limits for the client: Establishing clear behavioral limits is crucial for maintaining safety and order in the psychiatric unit. It helps ensure that the client understands what is expected of them and the consequences of unacceptable behavior. This is particularly important if the client has exhibited aggressive behavior, as it helps prevent further incidents and maintains a safe environment for everyone.
D. Establish a client relationship: Building a therapeutic relationship is essential for effective treatment, but it should be done in the context of a safe environment where clear behavioral expectations have already been established.
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Related Questions
Correct Answer is A
Explanation
Remaining with the client provides support and ensures their safety. The client's behavior indicates distress, and having a nurse nearby can help the client feel more comfortable and secure.
B. Give the client a PRN sleeping medication:
Explanation: Administering a sleeping medication should not be the first response, especially if the client is agitated. It's important to address the underlying cause of the agitation and consider other interventions before resorting to medication.
C. Encourage the client to go back to bed:
Explanation: Encouraging the client to go back to bed might not be effective if they are experiencing significant distress or anxiety. It's better to address their emotional state first before suggesting any changes in activity.
D. Explore alternatives to pacing the floor with the client:
Explanation: This is a reasonable course of action. Exploring alternatives to the client's current behavior can help address their distress and find ways to manage their emotions more effectively.
Correct Answer is ["2"]
Explanation
To calculate the number of capsules that the nurse should administer per dose, the nurse should first divide the total daily dose of tetracycline by the number of doses per day. This gives the dose per administration:
2 grams / 4 doses = 0.5 grams per dose
Next, the nurse should convert the dose from grams to milligrams, since the available capsules are in milligrams. There are 1000 milligrams in one gram, so the nurse should multiply the dose by 1000:
0.5 grams x 1000 mg/g = 500 mg per dose
Finally, the nurse should divide the dose in milligrams by the strength of each capsule, which is 250 mg. This gives the number of capsules that the nurse should administer per dose:
500 mg / 250 mg/capsule = 2 capsules per dose
Therefore, the nurse should administer 2 capsules of tetracycline every 6 hours to the client.
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