You find a patient on the floor at shift change. She is awake and alert. She is confused now and was not controlled before being found on the floor.

What is your first step in the nursing process in this situation?

Involuntary admission to a mental health unit is done when an individual poses a threat to themselves or others due to a mental health condition. The initial hold is usually for 72 hours, during which the client's condition is assessed and an appropriate treatment plan is developed. If the client is still deemed to be a danger to themselves or others after the initial hold, the healthcare provider may request an extension of the hold or seek a court order to continue treatment.

In order to keep the client in the hospital, it must be determined that they continue to pose a threat to themselves or others.

Factors such as the client's ability to make arrangements to stay with someone or financial capability to pay for medications are not relevant to the decision of whether to continue the hold.

Similarly, unwillingness to accept treatment is not the determining factor, as involuntary treatment can be provided to clients who do not recognize their need for treatment if they are deemed to be a danger to themselves or others.

This response is empathetic and allows the client to express her feelings openly. It demonstrates active listening and validates the client's emotions.

Option A ("I know exactly how you feel") can come across as dismissive or assuming, and it may not accurately reflect the client's unique experience.

Option B ("Most people experience depressed feelings after a divorce") may also come across as dismissive and minimizes the client's feelings.

Option C ("Look on the bright side, you will be glad you divorced him in a couple of years") is not empathetic and does not acknowledge the client's current emotional state.