A nurse on a mental health unit observes a client yelling at another client. Which of the following actions should the nurse take first?
State expectations for the client's behavior.
Request security personnel restrain the client.
Place the client in seclusion.
Debrief staff members about the conflict.
The Correct Answer is A
The correct answer is Choice A.
Choice A rationale: By stating expectations for the client’s behavior, the nurse is addressing the immediate situation and setting clear boundaries. This intervention allows the nurse to assertively communicate with the client, reminding them of appropriate behavior and potentially diffusing the situation1.
Choice B rationale: Requesting security personnel to restrain the client should be a last resort, used only when the client poses a significant risk to themselves or others and all other de-escalation techniques have failed. Restraint can be traumatic and has potential physical and psychological risks.
Choice C rationale: Placing the client in seclusion is another measure that should be used sparingly and only when necessary for the safety of the client or others. It’s important to try less restrictive measures first, such as verbal de-escalation techniques or offering a quiet, private space where the client can regain control.
Choice D rationale: Debriefing staff members about the conflict is an important step, but it should not be the first action. The immediate priority is to ensure the safety of all clients and to de-escalate the situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Veracity refers to the ethical principle of truthfulness and honesty in communication. By communicating truthfully about the adverse effects of the client's prescribed medications, the nurse is practising veracity. This means providing accurate and complete information to the client, enabling them to make informed decisions about their healthcare.
Beneficence refers to the obligation of healthcare professionals to act in the best interests of the client and promote their well-being. While the nurse's actions may align with beneficence by providing information about medication adverse effects, it is specifically veracity that is demonstrated in this scenario.
Justice pertains to fairness and equal treatment. Although important in healthcare, it is not directly related to the nurse's communication of adverse effects.
Autonomy refers to respecting and supporting the client's right to make their own decisions about their care. While the nurse's truthful communication about adverse effects supports the client's autonomy, it is the concept of veracity that specifically addresses honesty and truthfulness in communication.
Correct Answer is B
Explanation
This response allows the nurse to actively listen to the client, gain a better understanding of their concerns and reasons behind wanting to stop treatment, and open the door for a more in-depth conversation. It demonstrates a non-judgmental approach and creates an opportunity for the client to express their fears, concerns, or any other factors influencing their decision.
"I would feel the same way if I were you." This response reflects the nurse's personal opinion and may not accurately represent the client's thoughts or feelings. It does not encourage the client to explore their own feelings or provide an opportunity for open communication.
"Why do you think that would be a good choice?" This response may come across as confrontational and judgmental, potentially making the client defensive or shutting down communication. It does not facilitate a therapeutic conversation or encourage the client to express their emotions and concerns openly.
"You'll be cancer-free after you complete your treatments." This response may oversimplify the client's situation or offer false reassurance. It is important to acknowledge the client's feelings and concerns while providing accurate information and support, rather than making unrealistic promises about treatment outcomes.
The nurse should approach the client's expression of wanting to stop treatment with empathy, active listening, and an open mind to provide the necessary support, education, and resources to help the client make informed decisions about their healthcare.
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