A nurse who works in a psychiatric unit is caring for a client diagnosed with bipolar disorder. The client comes to the nurse's station at 0300, demanding that the nurse call the provider immediately. Which of the following responses should be an appropriate response by the nurse?
"I can't call a doctor in the middle of the night unless it's an emergency."
"You must be very upset about something."
"Go back to your room, and I'll try to get in touch with your doctor."
"You are being unreasonable, and I will not call your doctor at this hour."
The Correct Answer is B
Choice A: "I can't call a doctor in the middle of the night unless it's an emergency."
This response may seem reasonable, but it could escalate the situation if the client feels their concerns are not being taken seriously. It's important to validate the client's feelings and find a solution that respects both their needs and the realities of the situation.
Choice B: "You must be very upset about something."
This response validates the client's feelings and opens up a dialogue. It shows empathy and understanding, which can help de-escalate the situation.
Choice C: "Go back to your room, and I'll try to get in touch with your doctor."
This response acknowledges the client's request and provides a clear action plan. However, it's important to follow through on this promise to maintain trust.
Choice D: "You are being unreasonable, and I will not call your doctor at this hour."
This response is confrontational and likely to escalate the situation. It's important to remain calm and professional, even when dealing with difficult behavior.
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Related Questions
Correct Answer is A
Explanation
Choice A reason:
When a client expresses thoughts of wanting to end their life, it is crucial for the nurse to immediately assess the risk of suicide. Asking the client if they have a plan to commit suicide is a direct approach to gauge the immediacy and seriousness of the risk. This information is vital for determining the next steps in care, which may include close supervision, safety precautions, and urgent psychiatric evaluation.
Choice B reason:
While ensuring the client is comfortable is important, allowing the client to rest without further assessment or intervention may not be safe if the client is at immediate risk of self-harm. The priority is to assess and secure the client's safety.
Choice C reason:
It is inappropriate and potentially dangerous to dismiss the client's statement as manipulation. All expressions of suicidal ideation should be taken seriously, and the nurse should provide a supportive response that addresses the client's emotional state and safety concerns.
Choice D reason:
Notifying the client's family can be part of a broader safety plan, but it should not replace immediate assessment and intervention by the healthcare team. Family members may provide support, but they are not a substitute for professional care and suicide risk assessment.
Correct Answer is D
Explanation
Choice A reason:
The client experiencing withdrawal symptoms should be monitored, as these symptoms can range from mild to severe. Withdrawal symptoms may include fatigue, depression, and anxiety, which are significant but generally not life-threatening. The nurse should provide supportive care and monitor the client's vital signs and emotional state.
Choice B reason:
If the client is experiencing hallucinations, this indicates a more severe level of withdrawal and possibly the presence of a stimulant-induced psychotic disorder. While hallucinations can be distressing and require intervention, they are not the highest priority when compared to the risk of self-harm or harm to others.
Choice C reason:
The risk for traumatic re-experiencing, or flashbacks, is a concern during withdrawal, particularly if the client has a history of trauma. These experiences can be highly distressing and may lead to further psychological distress. However, the immediate physical safety of the client and others takes precedence.
Choice D reason:
The risk of self-harm or harm to others is the most critical safety concern and must be prioritized. Clients withdrawing from stimulants may exhibit increased agitation, aggression, or impulsivity, which can lead to dangerous behaviors. The nurse must take immediate action to ensure a safe environment, which may include close supervision, the use of restraints, or rapid pharmacological intervention.
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