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: Document the client's behavior once every hour. While documenting the client's behavior is important, it should be done more frequently than once every hour. Monitoring should be continuous to ensure the client's safety.

B reason: Keep the client in restraints until the prescription expires. Restraints should be used for the shortest duration necessary to ensure safety, not just until the prescription expires. Regular assessments are needed to determine if they can be removed earlier.

C reason: Conduct a debriefing regarding the client with the unit staff. Debriefing with the unit staff helps ensure everyone is informed about the client's condition, the reasons for using restraints, and the plan for ongoing care. This promotes a team approach to managing the client's behavior.

D reason: Request an evaluation of the client within 12 hours of application of restraints. An evaluation should be conducted much sooner than 12 hours, typically within an hour of applying restraints, to assess the client's physical and mental status and determine if continued use is justified.

A. Voice alteration. B. Neck pain. C. Memory deficit. D. Headache.

Correct Answer is C

Explanation

A reason: Voice alteration. Voice alteration is not a common adverse effect of ECT. The procedure typically does not impact vocal cords or speech directly.

B reason: Neck pain. While discomfort and muscle soreness can occur, neck pain is not a primary or common adverse effect specifically associated with ECT.

C reason: Memory deficit. Memory deficits, particularly short-term memory loss, are a well-documented adverse effect of ECT. Clients may experience difficulty recalling recent events before and after treatment.

D reason: Headache. Headache can occur after ECT but is less concerning compared to cognitive side effects like memory deficits. Monitoring for memory changes is crucial.

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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

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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