A nurse is caring for a client who has a history of aggression and is threatening to harm the staff on the unit.
Which of the following actions should the nurse take first?
Place the client in seclusion.
Use verbal de-escalation techniques to calm the client.
Offer the client a medication to help them calm down.
Arrange for a critical incident debriefing with the staff.
The Correct Answer is B
Choice A rationale
Placing a client in seclusion involves isolating them in a safe area to prevent harm to themselves or others. While seclusion may be necessary if de-escalation fails and the client poses an immediate threat, it should not be the first action. Less restrictive interventions should be attempted first to address the client's agitation and potential aggression.
Choice B rationale
Verbal de-escalation techniques are the initial and least restrictive interventions for managing a client who is threatening harm. These techniques involve using calm communication, active listening, empathy, and setting clear limits to help the client regain control and reduce their agitation without resorting to more restrictive measures.
Choice C rationale
Offering medication to calm the client may be considered if verbal de-escalation is ineffective and the client's agitation escalates. However, it is not the first action. A thorough assessment of the client's condition and the reason for their agitation should precede medication administration, and it should be used in conjunction with other de-escalation strategies.
Choice D rationale
Arranging for a critical incident debriefing with the staff is an important step after a crisis situation has been resolved to review the event, support staff, and identify areas for improvement. However, it is not the immediate action to take when a client is actively threatening harm to staff. The immediate priority is to ensure the safety of the client and staff.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale: Reinforce teaching on coping strategies
Teaching and reinforcing healthy coping mechanisms is essential in substance use recovery. The client has already identified some strategies, but ongoing education helps strengthen their ability to manage cravings, stress, and triggers.
Choice B rationale: Administer disulfiram
Disulfiram is used for alcohol dependence, but this client primarily uses heroin and methamphetamine—not alcohol. Since disulfiram is ineffective for opioid or stimulant addiction, this intervention is not appropriate.
Choice C rationale: Motivational interviewing
Motivational interviewing is an effective technique that helps enhance the client’s motivation for change while exploring ambivalence toward recovery. Given the client’s uncertainty about post-discharge living arrangements and social influences, this approach would encourage self-reflection and goal-setting.
Choice D rationale: Promote sleep
Many individuals undergoing withdrawal struggle with disrupted sleep, which can worsen irritability, anxiety, and relapse risk. Encouraging adequate rest improves emotional stability and overall health.
Choice E rationale: Encourage personal hygiene
Substance use can lead to neglect of self-care, so promoting personal hygiene reinforces self-respect, routine-building, and overall well-being. This small yet impactful intervention supports mental health recovery.
Choice F rationale: Encourage codependence
Encouraging codependence is not a recommended practice in substance use recovery. Codependence often leads to unhealthy emotional reliance, enabling behaviors, and difficulty maintaining independence post-rehabilitation.
Correct Answer is D
Explanation
Choice A rationale
Encouraging a child to focus solely on the future after a sexual assault can minimize the impact of the trauma and discourage processing the difficult emotions associated with the event. A positive support system allows the child to acknowledge and work through their feelings, not avoid them.
Choice B rationale
Suggesting that the child think about what they did to allow the assault to happen places blame on the victim. A positive support system emphasizes that the assault was not the child's fault and focuses on support and healing, not assigning blame.
Choice C rationale
While concern for the child's well-being is understandable, attempting to monitor all of their relationships can be overly controlling and undermine the child's autonomy and trust. A positive support system balances safety with respect for the child's personal boundaries and development.
Choice D rationale
Anticipating that the child will feel some self-blame is a realistic and empathetic understanding of the potential psychological impact of sexual assault. Survivors often internalize blame, even though they are not at fault. Acknowledging this possibility allows the guardian to provide appropriate support and reassurance.
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