A nurse is caring for a client who has become violent and is threatening self-harm following a crisis. After ensuring enough staff are available, which of the following actions should the nurse take first?

Administer a sedative medication.

Perform a debriefing with the staff.

Acknowledge the client's emotions.

Place the client in restraints.

Answer and Explanation

The Correct Answer is C

A reason: Administer a sedative medication. While administering a sedative may be necessary to calm the client, it is not the first step. The nurse should initially attempt to de-escalate the situation using non-pharmacological interventions.

B reason: Perform a debriefing with the staff. Debriefing with the staff is important after the situation is under control, but it is not the immediate priority. The focus should first be on addressing the client's behavior and emotions.

C reason: Acknowledge the client's emotions. Acknowledge the client's emotions to de-escalate the situation and help the client feel heard and understood. This can reduce the immediate risk of violence or self-harm.

D reason: Place the client in restraints. Restraints should be used as a last resort when other interventions have failed and there is an immediate risk of harm. The nurse should first try to calm the client through verbal and emotional support.

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Correct Answer is D

Explanation

A reason: Delusion. A delusion is a false belief held despite clear evidence to the contrary. While the client's statement might reflect a distorted perception of reality, the expression of wanting to use a pen to "cut the pain out" indicates a more immediate risk of self-harm.

B reason: Hallucination. Hallucinations involve perceiving something that is not present, such as hearing voices or seeing things that are not there. The client's statement does not indicate a hallucination, but rather a desire to engage in self-harm.

C reason: Attention-seeking behavior. While attention-seeking behavior might be a consideration, the specific request to use a pen to harm themselves suggests a more severe risk of self-mutilation rather than merely seeking attention.

D reason: Self-mutilation. The client's statement clearly indicates a risk for self-mutilation. Expressing the intention to use a pen to harm themselves requires immediate intervention to ensure their safety.

A. Spending equal time with clients regardless of their insurance status. B. Explaining possible adverse effects to clients receiving new prescriptions. C. Respecting the decision of clients to refuse to participate in group therapy. D. Attending an educational conference on identifying clients at risk for suicide.

Correct Answer is C

Explanation

A reason: Spending equal time with clients regardless of their insurance status. This action is an example of justice, which involves providing fair and equal treatment to all clients.

B reason: Explaining possible adverse effects to clients receiving new prescriptions. This action is an example of veracity, which involves being honest and providing accurate information to clients.

C reason: Respecting the decision of clients to refuse to participate in group therapy. This action exemplifies fidelity, which involves being faithful to commitments and respecting the client's autonomy and decisions, even when they choose to refuse treatment or participation.

D reason: Attending an educational conference on identifying clients at risk for suicide. This action demonstrates a commitment to professional development and competence, but it does not specifically exemplify the ethical concept of fidelity in client care.

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A nurse is caring for a client who has become violent and is threatening self-harm following a crisis. After ensuring enough staff are available, which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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