A nurse is preparing to change the dressing on the lower leg of an older adult client who is in a wheelchair, and has a history of maladaptive coping skills. The client begins swearing at and verbally abusing the nurse. Which of the following actions should the nurse take?
Explain to the client why her behavior is inappropriate.
Tell the client when he will return and leave the room.
Place wrist restraints on the client to prevent psychomotor agitation.
Move the client to a seclusion room.
The Correct Answer is B
By calmly informing the client when the nurse will return and then leaving the room, the nurse establishes clear boundaries and removes themselves from the situation to ensure their own safety. It allows the nurse to disengage from the abusive behavior and avoid escalating the situation further.
Let's review the other options and explain why they are not appropriate in this situation:
A. Explaining to the client why their behavior is inappropriate may not be effective in the moment when the client is already agitated and verbally abusive. Attempting to reason with or educate the client during this state could potentially escalate the situation or prolong the abusive behavior.
C. Placing wrist restraints on the client should only be done in exceptional circumstances when there is an imminent risk of harm to themselves or others. Verbal abuse, while unpleasant, does not necessarily warrant the use of restraints as a first-line intervention.
D. Moving the client to a seclusion room is also an extreme measure and should only be considered if the client's behavior poses a significant risk to themselves or others and less restrictive interventions have been exhausted. Verbal abuse alone would not typically warrant seclusion.
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Related Questions
Correct Answer is C
Explanation
This statement implies that the nurse is taking sides and suggesting a specific course of action to the client. It is important for the nurse to remain neutral and non-directive during family therapy sessions. The nurse's role is to facilitate open communication, active listening, and understanding between the family members, rather than imposing their own opinions or suggesting specific solutions.
To ensure a therapeutic and unbiased approach, the nurse should intervene and provide feedback to the newly licensed nurse, reminding them to maintain a neutral stance and encourage the client to explore their own perspectives and feelings about the relationship.
Incorrect:
A. "We should invite your partner to be a part of our discussion." This statement suggests involving the partner, which is a common practice in family therapy. It recognizes the importance of including all relevant family members in the therapeutic process.
B. "Tell me about the concerns that you have regarding your relationship." This statement encourages the client to express their concerns and provides an opportunity for them to share their thoughts and feelings about the relationship. It promotes open communication and active listening.
D. "Relationship difficulties are stressful and require effort to resolve." This statement acknowledges the challenges in relationships and emphasizes the need for active participation and effort to address and resolve issues. It sets a realistic expectation for the client and supports their engagement in the therapeutic process.
Correct Answer is C
Explanation
This response acknowledges the client's need for assistance while redirecting the focus towards exploring alternative solutions. It demonstrates the nurse's willingness to help and initiates a collaborative problem-solving approach. By engaging in a discussion about available resources, the nurse can help the client explore options such as home delivery services, community support programs, or involving family and friends in assisting with grocery shopping.
Let's review the other options and explain why they are not the most appropriate responses:
A. "I won't be able to shop for you today because I have to get home to my family." This response lacks empathy and doesn't address the client's needs. It is important for the nurse to prioritize the client's well-being and explore appropriate solutions rather than providing personal reasons for not being able to assist.
B. "What I think you should do is wait for the days when you feel better and do your grocery shopping then." This response overlooks the client's current limitations and implies that the client should solely rely on their own abilities, which may not be feasible or practical for the client.
D. "I would be happy to do whatever I can to help you." While this response conveys the nurse's willingness to assist, it is important to remember that shopping and performing personal errands are typically outside the scope of a home care nurse's responsibilities. It is more appropriate to explore other resources and options to address the client's needs effectively.
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