A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?
Remain with the client.
Give to client a PRN sleeping medication,
Encourage the client to go back to bed.
Explore alternatives to pacing the floor with the client.
The Correct Answer is A
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.
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Related Questions
Correct Answer is C
Explanation
A. The client is unwilling to accept that treatment is needed.
This alone may not be sufficient to keep the client under a 72-hour hold. While a person's refusal to accept treatment may indicate a need for care, it might not meet the criteria for involuntary commitment unless there is an immediate danger to the individual or others.
B. The client states that she does not like the neighbor.
Disliking a neighbor is not typically a sufficient reason to place someone under a 72-hour psychiatric hold. The criteria for involuntary commitment usually revolve around a person's potential to harm themselves or others due to their mental state.
C. The client is a danger to herself or others.
Explanation:
In many jurisdictions, a 72-hour psychiatric hold, also known as an involuntary psychiatric hold or emergency detention, allows mental health professionals to detain a person who is considered a danger to themselves or others due to their mental condition. This is done to ensure the safety of the individual and those around them. The hold provides a brief period during which a psychiatric assessment can be conducted to determine the appropriate course of action for the person's mental health treatment.
D. The client states that she plans to move out of the state immediately.
While this statement might raise concerns about the client's stability, it generally would not meet the criteria for a 72-hour hold unless there is clear evidence that the client's immediate move would pose a risk to their own safety or the safety of others. The hold is more focused on imminent danger rather than potential future actions.
Correct Answer is B
Explanation
While addressing self-esteem and positive personality traits is important for overall psychological well-being, it is not the priority during the acute detoxification phase. Ensuring the client's physical safety and stability is the immediate concern.
B. Providing for adequate hydration and rest.
Explanation: The process of detoxification from alcohol can lead to withdrawal symptoms, some of which can be severe and even life-threatening. Adequate hydration is crucial during this period to prevent dehydration and electrolyte imbalances that can occur due to excessive vomiting, diarrhea, or sweating associated with withdrawal. Rest is also important to help the client's body recover from the physical stress of withdrawal.
C. Educating the client about the consequences of alcohol misuse.
Education about the consequences of alcohol misuse is important for the client's understanding and motivation for recovery, but this intervention can come after addressing the immediate physical needs of detoxification.
D. Confronting the use of denial and other defense mechanisms.
Addressing denial and defense mechanisms is a critical aspect of therapy for clients with alcohol use disorder, but it might not be the first priority during the detoxification phase. Ensuring the client's physical safety and managing withdrawal symptoms take precedence initially.
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