A nurse in a mental health facility is caring for a client who is being aggressive toward other clients. Which of the following actions is the priority for the nurse to take?
Role model healthy ways to express anger.
Suggest the client make a list of things that make him angry.
Assist the client to explore techniques to reduce stress.
Ask the client if he intends to harm others.
The Correct Answer is D
The priority for the nurse is to ensure safety for the client and others in the facility. Asking the client about his or her intentions can help the nurse determine the level of risk and plan appropriate interventions, such as setting limits, providing supervision, or initiating seclusion or restraint if necessary.
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Correct Answer is B
Explanation
Choice A reason:
Obtaining the provider's prescription within 60 min is not the immediate action required in this scenario. The priority is to ensure the safety of the client and others, which is achieved by continuous monitoring and documentation.
Choice B reason:
Documenting the client's behavior every 15 min is crucial in managing physically aggressive clients in seclusion. This allows the healthcare team to monitor the client's condition closely and make necessary interventions promptly.
Choice C reason:
Monitoring the client's vital signs every 4 hr may not be frequent enough for a client in seclusion who has been physically aggressive. The client's condition could change rapidly, and more frequent monitoring might be necessary.
Choice D reason:
Offering food and fluids every 2 hr is important for maintaining the client's physical health, but it is not the primary action in managing a physically aggressive client in seclusion. The immediate focus should be on ensuring safety and managing the client's aggressive behavior.
Correct Answer is D
Explanation
Bupropion is contraindicated in clients who have a history of seizures or head trauma, as it can lower the seizure threshold and increase the risk of adverse effects.
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