A patient demonstrating behaviors associated with acute mania has exhausted the staff by noon. Staff members are feeling defensive and fatigued. Which action should the staff take initially to prevent this issue?
Confer with the health care provider to consider use of seclusion for this patient.
Hold a staff meeting to discuss consistency and limit-setting approaches.
Explain to the patient that the behavior is unacceptable.
Conduct a meeting with all staff and patients to discuss the behavior.
The Correct Answer is B
A. Seclusion is a last-resort intervention, not an initial step.
B. Staff meetings to ensure consistent approaches, structure, and limit-setting prevent staff fatigue, reduce defensiveness, and provide therapeutic consistency for the client.
C. Confronting the patient directly about unacceptable behavior may escalate agitation and is not the most effective prevention strategy.
D. Group discussions with patients about one individual’s behavior would be inappropriate and non-therapeutic.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Justice refers to fairness and equality in the distribution of care and resources. The nurse is concerned about whether patients exhibiting similar behaviors (self-mutilation) are being treated consistently and fairly, which directly relates to the principle of justice.
B. Fidelity involves keeping promises and commitments to patients, which is not the primary concern in this scenario.
C. Beneficence involves acting in the patient’s best interest to promote well-being. While relevant to care decisions, the main ethical issue here is fairness between patients.
D. Autonomy involves respecting a patient’s right to make their own decisions, which is not the central issue in comparing the care of two patients.
Correct Answer is C
Explanation
A. This involves memory loss due to brain injury or alcohol abuse, not acute fluctuating confusion.
B. Alzheimer’s causes progressive, irreversible memory decline that develops gradually, not suddenly over 2 days.
C. Delirium is characterized by acute onset, fluctuating levels of orientation, confusion, speech changes, and impaired gait, often triggered by medications, infections, or metabolic issues.
D. Dementia develops slowly and progressively, not suddenly like delirium.
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