A nurse is caring for a client who becomes verbally abusive when the nurse enters her room. Which of the following actions should the nurse take?

Leave the client's room

Maintain eye contact until the behavior stops.

Tell the client her behavior is disappointing.

Punish the client for the behavior.

Answer and Explanation

The Correct Answer is A

It is essential for the nurse's safety and well-being to remove themselves from a situation where the client is exhibiting verbally abusive behavior. Leaving the room allows the nurse to distance themselves from the confrontational environment and ensures their physical and emotional safety. Continuing to engage with the client may escalate the situation further and put the nurse at risk.

Incorrect:

B. Maintain eye contact until the behavior stops: Maintaining eye contact may be perceived as confrontational or provocative, which can further escalate the situation. It is advisable for the nurse to disengage from the client's presence to avoid potential harm.

C. Tell the client her behavior is disappointing: Engaging in a confrontational or judgmental response can exacerbate the client's anger or aggression. It is important for the nurse to maintain a professional and therapeutic approach while ensuring personal safety.

D. Punish the client for the behavior: Punishment is not an appropriate response to verbally abusive behavior. It can damage the nurse-client relationship and potentially worsen the client's emotional state. Promoting a supportive and therapeutic environment is key in managing challenging behaviors.

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Correct Answer is C

Explanation

Involuntary commitment refers to the legal process by which an individual is admitted to a psychiatric facility for treatment against their will. The decision to involuntarily commit someone is typically based on the assessment that their behavior poses a risk of harm to themselves or others. Therefore, it is important for the nurse to inform the client's family that the reason for the involuntary commitment is the client's behavior being a threat to their own safety or the safety of others.

A."A psychiatrist determines that the client's behavior is irrational." This statement is incorrect because irrational behavior alone is not sufficient grounds for involuntary commitment.

Involuntary commitment is typically based on the assessment that the individual's behavior poses a risk of harm to themselves or others, rather than solely on the basis of irrational behavior.

B. "The client is unable to manage the affairs necessary for daily life." While the inability to manage daily affairs may be a factor considered in the overall assessment of a client's condition, it is not the sole criterion for involuntary commitment. Involuntary commitment is primarily focused on the risk of harm posed by the individual's behavior, rather than their ability to manage daily life tasks.

D. "The client has been accused of breaking the law." Accusations of breaking the law are not the basis for involuntary commitment. Involuntary commitment is based on the assessment that the individual's behavior presents a risk of harm to themselves or others. Legal issues are addressed separately through the legal system and are not directly related to the criteria for involuntary commitment.

A. Get the client ready for sleep at the same time each night. B. Move the client to a room next to the open nurses' station. C. Encourage client to take a 1-hr nap each afternoon. D. Play the client's favorite music in the room while the client is sleeping.

Correct Answer is A

Explanation

Establishing a consistent bedtime routine and sleep schedule can promote better sleep hygiene and help regulate the client's sleep-wake cycle. By getting the client ready for sleep at the same time each night, the nurse helps create a predictable and calming routine that signals to the body that it is time to sleep.

Incorrect:

B. Move the client to a room next to the open nurses' station: This measure may increase noise and disturbances, which can further disrupt the client's sleep. Providing a quiet and peaceful environment is generally more conducive to restful sleep.

C. Encourage the client to take a 1-hour nap each afternoon: While short daytime naps can be beneficial for some individuals, they may interfere with the client's ability to fall asleep or stay asleep at night. It is generally recommended to limit daytime napping, especially if the client is having trouble sleeping at night.

D. Play the client's favorite music in the room while the client is sleeping: While some individuals find soothing music helpful for relaxation and sleep, it is essential to consider the client's preferences. Not everyone finds music helpful for sleep, and it is important to respect the client's preferences and individual needs. Some clients may find silence or white noise more conducive to sleep.

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