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 B

Explanation

Choice A reason:

Obtaining the provider's prescription within 60 min is not the immediate action required in this scenario. The priority is to ensure the safety of the client and others, which is achieved by continuous monitoring and documentation.

Choice B reason:

Documenting the client's behavior every 15 min is crucial in managing physically aggressive clients in seclusion. This allows the healthcare team to monitor the client's condition closely and make necessary interventions promptly.

Choice C reason:

Monitoring the client's vital signs every 4 hr may not be frequent enough for a client in seclusion who has been physically aggressive. The client's condition could change rapidly, and more frequent monitoring might be necessary.

Choice D reason:

Offering food and fluids every 2 hr is important for maintaining the client's physical health, but it is not the primary action in managing a physically aggressive client in seclusion. The immediate focus should be on ensuring safety and managing the client's aggressive behavior.

A. Role model healthy ways to express anger. B. Suggest the client make a list of things that make him angry. C. Assist the client to explore techniques to reduce stress. D. Ask the client if he intends to harm others.

Correct Answer is D

Explanation

The priority for the nurse is to ensure safety for the client and others in the facility. Asking the client about his or her intentions can help the nurse determine the level of risk and plan appropriate interventions, such as setting limits, providing supervision, or initiating seclusion or restraint if necessary.

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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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