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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A reason: This medication will help control my child's aggressive behavior. Risperidone is often prescribed to manage irritability and aggressive behaviors in children with autism spectrum disorder. This statement accurately reflects one of the medication's intended effects.
B reason: This medication can cause my child to have low blood sugar. Risperidone is not known to cause low blood sugar. It can, however, cause other metabolic side effects like weight gain and increased cholesterol levels.
C reason: This medication won't require my child to have routine lab tests. Routine lab tests are often necessary when taking risperidone to monitor for potential side effects, such as metabolic changes and blood glucose levels.
D reason: This medication might need to be increased if my child has muscle spasms. Muscle spasms or extrapyramidal symptoms may occur with risperidone, but they typically require management with adjunct medications rather than increasing the dosage.
Correct Answer is D
Explanation
A reason: Refer the client to a support group for survivors of suicide. While referring the client to a support group is important for long-term support, it is not the immediate priority in this acute moment of grief.
B reason: Offer to contact the client's family or support system. Offering to contact family or support systems is supportive but not the first priority. The nurse should first assess the client's immediate emotional and cognitive state.
C reason: Inform the client that feelings of guilt are often felt by survivors of suicide. Providing information about common feelings of guilt can be helpful, but the nurse should first understand the client's current state and their specific needs.
D reason: Determine the client's understanding of the suicide events. The first priority is to assess the client's understanding and emotional response to the news. This helps the nurse provide appropriate support and address any immediate misconceptions or distress.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.