A nurse is caring for a client who has become violent and is threatening self-harm following a crisis. After ensuring enough staff are available, which of the following actions should the nurse take first?

Administer a sedative medication.

Perform a debriefing with the staff.

Acknowledge the client's emotions.

Place the client in restraints.

Answer and Explanation

The Correct Answer is C

A reason: Administer a sedative medication. While administering a sedative may be necessary to calm the client, it is not the first step. The nurse should initially attempt to de-escalate the situation using non-pharmacological interventions.

B reason: Perform a debriefing with the staff. Debriefing with the staff is important after the situation is under control, but it is not the immediate priority. The focus should first be on addressing the client's behavior and emotions.

C reason: Acknowledge the client's emotions. Acknowledge the client's emotions to de-escalate the situation and help the client feel heard and understood. This can reduce the immediate risk of violence or self-harm.

D reason: Place the client in restraints. Restraints should be used as a last resort when other interventions have failed and there is an immediate risk of harm. The nurse should first try to calm the client through verbal and emotional support.

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Correct Answer is C

Explanation

A reason: Provide additional attention to the client. While providing support and attention is important, it can reinforce attention-seeking behaviors in clients with borderline personality disorder. The care plan should balance support with boundaries.

B reason: Apply mechanical restraints before administering medication. Using restraints as a first-line intervention is not appropriate and should be avoided unless there is an immediate risk of harm. Less restrictive measures should be used initially.

C reason: Obtain a verbal contract from the client. A verbal contract, or a no-harm agreement, can be an effective strategy to engage the client in their own safety plan and reduce the risk of self-mutilation. It encourages the client to commit to seeking help before engaging in self-harm.

D reason: Limit staff members who work with the client. Consistency in care is important for clients with borderline personality disorder to build trust and maintain clear communication. Limiting staff changes helps provide stable and predictable care.

A. "ECT is contraindicated in clients who have psychotic symptoms." B. "ECT is delivered through electrodes attached to the head." C. "ECT cannot be administered to clients who have suicidal ideation." D. "ECT is conducted under regional anesthesia."

Correct Answer is B

Explanation

A reason: "ECT is contraindicated in clients who have psychotic symptoms." ECT is not contraindicated in clients with psychotic symptoms. In fact, ECT can be an effective treatment for certain types of severe mental illnesses, including those with psychotic features, particularly when other treatments have failed.

B reason: "ECT is delivered through electrodes attached to the head." This statement accurately describes a key aspect of the ECT procedure. Electrodes are placed on the client's scalp to deliver electrical impulses, which induce a brief seizure intended to alleviate symptoms of major depressive disorder.

C reason: "ECT cannot be administered to clients who have suicidal ideation." ECT can be administered to clients with suicidal ideation and is sometimes used when rapid improvement in mood and reduction of suicidal thoughts are needed. It can be an effective treatment option in such cases.

D reason: "ECT is conducted under regional anesthesia." ECT is actually conducted under general anesthesia, not regional anesthesia. General anesthesia ensures the client is unconscious and does not feel pain during the procedure.

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A nurse is caring for a client who has become violent and is threatening self-harm following a crisis. After ensuring enough staff are available, which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a client who has borderline personality disorder and is at risk for self-mutilation. Which of the following interventions should the nurse incorporate in the plan of care?

Correct Answer is C

Explanation

A nurse is preparing to teach a client who has major depressive disorder and is scheduled to undergo electroconvulsive therapy (ECT). Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

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