A nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unit. Which of the following actions should the nurse take first?
Explain the client that the behavior was unacceptable.
Explore the truth of the client's statements.
Set behavioral limits for the client.
Establish a client relationship
The Correct Answer is C
A. Explain to the client that the behavior was unacceptable: While addressing the behavior is important, it is more effective to first establish clear limits and boundaries to prevent further incidents.
B. Explore the truth of the client’s statements: This step involves assessing the client's statements and understanding their perspective, which is important but can be done after setting behavioral limits.
C. Set behavioral limits for the client: Establishing clear behavioral limits is crucial for maintaining safety and order in the psychiatric unit. It helps ensure that the client understands what is expected of them and the consequences of unacceptable behavior. This is particularly important if the client has exhibited aggressive behavior, as it helps prevent further incidents and maintains a safe environment for everyone.
D. Establish a client relationship: Building a therapeutic relationship is essential for effective treatment, but it should be done in the context of a safe environment where clear behavioral expectations have already been established.
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Related Questions
Correct Answer is D
Explanation
A. "It doesn't really matter what time you take your medications as long as you don't skip any doses."
While it's important not to skip doses, taking medications at specific intervals is often necessary for maintaining therapeutic blood levels and optimal treatment outcomes. Disregarding specific timing can affect the effectiveness of the medications.
B. "We'll have to talk to your provider about switching to an alternative schedule."
This response may not consider the client's preferences and might not be necessary if the client's current schedule can be adjusted to suit their routine. Collaboration between the nurse and the client is essential.
C. "You really shouldn't change the schedule we established here in the facility."
While continuity in medication schedules is important, if the established schedule doesn't align with the client's daily life, there should be flexibility to adjust it in a way that still maintains the effectiveness of the medications.
D. "Let's work together to devise a time schedule that is convenient for you on a daily basis."
Explanation: It's important to consider the client's lifestyle and routines when developing a medication schedule to ensure optimal adherence. Collaboratively working with the client to create a schedule that fits their daily activities increases the likelihood that they will consistently take their medications as prescribed.
Correct Answer is D
Explanation
A. "Tell me about the concerns that you have regarding your relationship."
This choice is an appropriate and open-ended question that encourages the client to express their feelings and concerns. It helps in building rapport and understanding the client's perspective.
B. "Relationship difficulties are stressful and require effort to resolve."
This choice acknowledges the challenges of relationship difficulties and conveys a supportive and empathetic attitude. It is a reasonable and non-biased statement.
C. "We could develop a plan for how to talk about this with your partner."
This choice suggests a proactive approach to address the client's concerns and promote effective communication. It is a helpful and appropriate statement.
D. "You should try to see your partner's point of view before your own."
This statement implies a biased approach, suggesting that the client should prioritize their partner's perspective over their own. While empathy and understanding are important in relationships, it's not appropriate for a healthcare professional to imply that one perspective is more important than the other. The nurse should encourage open communication and understanding from both sides rather than favoring one viewpoint.
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