A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?

Stop the newly licensed nurse from administering the medication.

Demonstrate how to verbally de-escalate the situation.

Discuss the purpose of the medication with the client.

Assess the need for physical restraints.

Answer and Explanation

The Correct Answer is B

A. Stop the newly licensed nurse from administering the medication – While it is important to prevent the administration of medication against the client's will, the focus should initially be on de-escalation to address the client's refusal.

B. Demonstrate how to verbally de-escalate the situation – This is the most appropriate first action. De-escalation techniques can help calm the client and create a dialogue, potentially leading to a willingness to discuss the medication and its benefits.

C. discussing the medication's purpose, is also secondary to honoring the client's current refusal.

D. assessing the need for restraints, would be inappropriate without first stopping the medication administration and could escalate the situation. Therefore, the first and most critical action is to stop the medication administration.

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Correct Answer is A

Explanation

The correct answer is:

A. Implement continuous one-to-one observation.

Choice A reason:

Implementing continuous one-to-one observation is the most immediate and direct method to ensure the safety of a client who has been admitted after a suicide attempt. This involves assigning a staff member to stay with the client at all times, providing constant supervision to prevent self-harm. It is a standard safety measure in mental health facilities for clients at high risk of suicide.

Choice B reason:

While encouraging the client to participate in group therapy is a valuable part of the treatment plan, it is not the first action a nurse should take. Group therapy is beneficial for social support and developing coping strategies, but it is not an immediate safety measure for a client at risk of suicide.

Choice C reason:

Asking the client to sign a no-suicide contract can be part of the therapeutic process, but it is not the first step in acute care. These contracts involve the client agreeing not to harm themselves and to seek help if suicidal thoughts occur. However, they are not considered a substitute for active supervision and intervention.

Choice D reason:

Establishing a rapport to foster trust is crucial for effective nursing care and is an ongoing process. It helps in creating a therapeutic relationship, which is essential for the client's long-term recovery. However, it is not the immediate priority in a crisis situation where the client's safety is at risk.

A. Significant weight loss B. Markedly neglected hygiene C. Psychomotor retardation D. Poor problem-solving skills

Correct Answer is A

Explanation

Choice A reason:

Significant weight loss in a patient with major depressive disorder is a red flag for clinicians. It can signify a high risk of complications, including malnutrition, electrolyte imbalance, and weakened immunity. In the context of depression, it may also reflect a lack of self-care or even suicidal tendencies, which require immediate attention.

Choice B reason:

While markedly neglected hygiene is concerning and indicative of a patient's inability to perform daily self-care activities, it is not typically considered an immediate life-threatening issue. However, it does warrant intervention to prevent potential secondary infections or complications.

Choice C reason:

Psychomotor retardation is a symptom that can manifest in major depressive disorder, characterized by slowed physical movements and cognitive processing. Although it impacts the quality of life and daily functioning, it is not usually a direct indicator of an acute life-threatening condition.

Choice D reason:

Poor problem-solving skills are part of the cognitive symptoms of depression, affecting a patient's ability to manage daily tasks and make decisions. While this can significantly impact a patient's life, it is not as urgent as significant weight loss, which can have immediate physical health consequences.

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A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

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