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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. "I think you should calm down a little before you see your partner.":

Explanation: This response might come across as dismissive or insensitive to the partner's feelings. It's important to acknowledge the partner's emotions and offer support rather than suggesting they should calm down.

B. "Do not worry about that. Your wife will be fine.":

Explanation: While it's reassuring to say that the patient will be fine, dismissing the partner's feelings and concerns is not supportive. The partner needs a chance to express their emotions and concerns.

C. "Tell me more about your feelings about what happened to your partner.":

Explanation: Correct Answer. This response is empathetic and encourages the partner to express their emotions. It shows that the nurse is actively listening and is willing to provide a safe space for the partner to share their feelings.

D. "Why do you think the crash is your fault?":

Explanation: This response might come across as accusatory or confrontational, which could exacerbate the partner's feelings of guilt. Instead, the nurse should focus on providing support and understanding.

A. The client is unwilling to accept that treatment is needed B. The client states that she does not like the neighbor C. The client is a danger to herself or others D. The client states that she plans to move out of the state immediately

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.

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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?

Nursing Test Bank

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Explanation

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Explanation

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