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RN MENTAL HEALTH EXAM
RN MENTAL HEALTH EXAM ( 63 Questions)
A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?
Assess the need for physical restraints:Assessing the need for physical restraints is not the first action to take in this situation. Physical restraints should only be considered as a last resort when there is an immediate threat to the patient or others. It's essential to attempt verbal de-escalation techniques and other non-coercive interventions before considering physical restraints.
Discuss the purpose of the medication with the client:Discussing the purpose of the medication is an important step, as it can help the client understand why they are being asked to take it. However, it may not be the first action to take, especially if the client is highly agitated or manic. Attempting verbal de-escalation techniques, such as calming communication and active listening, should precede discussing the medication's purpose.
Stop the newly licensed nurse from administering the medication:
Stopping the newly licensed nurse from administering the medication without addressing the situation directly doesn't resolve the issue. It's important to equip the nurse with appropriate communication skills to handle the situation effectively. Preventing the administration of the medication is not the primary step; it's more about helping the nurse manage the situation appropriately.
Demonstrate how to verbally de-escalate the situation:This is the recommended first action. Demonstrating verbal de-escalation techniques is crucial when dealing with an agitated or manic patient. The nurse manager can model effective communication strategies to help the newly licensed nurse manage the situation without resorting to physical interventions or restraints. Effective verbal de-escalation can lead to a more peaceful resolution and, ideally, the patient's acceptance of the medication without confrontation.
A. Assess the need for physical restraints:
Assessing the need for physical restraints is not the first action to take in this situation. Physical restraints should only be considered as a last resort when there is an immediate threat to the patient or others. It's essential to attempt verbal de-escalation techniques and other non-coercive interventions before considering physical restraints.
B. Discuss the purpose of the medication with the client:
Discussing the purpose of the medication is an important step, as it can help the client understand why they are being asked to take it. However, it may not be the first action to take, especially if the client is highly agitated or manic. Attempting verbal de-escalation techniques, such as calming communication and active listening, should precede discussing the medication's purpose.
C. Stop the newly licensed nurse from administering the medication:
Stopping the newly licensed nurse from administering the medication without addressing the situation directly doesn't resolve the issue. It's important to equip the nurse with appropriate communication skills to handle the situation effectively. Preventing the administration of the medication is not the primary step; it's more about helping the nurse manage the situation appropriately.
D. Demonstrate how to verbally de-escalate the situation:
This is the recommended first action. Demonstrating verbal de-escalation techniques is crucial when dealing with an agitated or manic patient. The nurse manager can model effective communication strategies to help the newly licensed nurse manage the situation without resorting to physical interventions or restraints. Effective verbal de-escalation can lead to a more peaceful resolution and, ideally, the patient's acceptance of the medication without confrontation.