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 A
Explanation
This is an essential instruction for performing passive ROM exercises safely and effectively. Supporting the extremity above and below each joint helps to prevent injury and provides stability during the exercise. This technique also helps to minimize discomfort and maintain proper alignment of the joint.
Repeat each exercise movement 10 times: This instruction does not provide sufficient guidance on the number of repetitions and may be too general. The number of repetitions will depend on the client's condition and tolerance.
Position the bed at mid-thigh level: This instruction is not necessary for performing passive ROM exercises and may not be feasible in all settings.
Move each joint just past the point of resistance: This instruction can be harmful and may cause injury or pain. The nurse should encourage the family to move the joint gently and smoothly, within the range of motion that is comfortable for the client.
Correct Answer is A
Explanation
Maintaining confidentiality and protecting the privacy of clients is a fundamental responsibility of healthcare professionals.
When the nurse becomes aware of a conversation between APs that breaches this confidentiality, it is essential to intervene promptly.
The nurse should approach the APs and respectfully ask them to stop the conversation and remind them about the importance of maintaining client confidentiality.
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