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. Administer a sedative medication: While sedation may be necessary in some cases to manage acute agitation or aggression, it should not be the first action taken. Administration of sedative medication requires a careful assessment of the client's condition, potential drug interactions, and individualized dosing considerations. It's important to consider less restrictive interventions before resorting to sedation.

B. Perform a debriefing with the staff: Debriefing with the staff is an essential step in processing the crisis situation and ensuring the well-being of the team. However, it should not be the first action taken when the client is in immediate danger of harming themselves or others.

C. Acknowledge the client's emotions: Acknowledging the client's emotions and validating their feelings can help establish rapport and de-escalate the situation. However, if the client is actively threatening self-harm or violence, addressing safety concerns should take precedence.

D. Place the client in restraints: Restraints should only be used as a last resort and when less restrictive interventions have failed to ensure the safety of the client and others. Restraints should not be the first action taken, especially if there are other interventions that can be attempted to de-escalate the situation.

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Correct Answer is C

Explanation

A. Remain 15 cm (6 in) away from the client: Maintaining a safe physical distance is important to ensure the safety of both the client and the staff member. However, the specific distance may vary depending on the situation and the client's level of agitation. It's essential to maintain a safe distance while still engaging with the client in a supportive manner.

B. Use a raised voice when speaking to the client: Using a raised voice can escalate the situation further and may increase the client's agitation or aggression. It's important to speak calmly and softly to avoid escalating the situation.

C. Determine the cause of the client's feelings: Understanding the underlying reasons for the client's aggression can help the nurse address the root cause and implement appropriate interventions. It's important to listen actively to the client, validate their feelings, and demonstrate empathy.

D. Ask the client short close-ended questions: Close-ended questions typically elicit simple "yes" or "no" responses and may not encourage open communication or help the client express their feelings. Instead, it's more beneficial to ask open-ended questions that allow the client to express themselves and feel heard.

A. A client who is experiencing withdrawal from oxycodone. B. A client who is experiencing withdrawal from diazepam C. A client who has a low lithium level D. A client who has a low imipramine level

Correct Answer is B

Explanation

A. A client who is experiencing withdrawal from oxycodone: While withdrawal from opioids like oxycodone can cause various symptoms, including agitation, anxiety, and muscle aches, it's not typically associated with an increased risk of seizures.

B. A client who is experiencing withdrawal from diazepam: Withdrawal from benzodiazepines like diazepam can indeed increase the risk of seizures. Abrupt cessation of benzodiazepines after prolonged use can lead to withdrawal symptoms, including seizures. Therefore, seizure precautions would be appropriate for this client.

C. A client who has a low lithium level: Low lithium levels can potentially lead to lithium toxicity, which can cause various symptoms, but seizures are not commonly associated with low lithium levels. However, in severe cases of lithium toxicity, seizures can occur.

D. A client who has a low imipramine level: Imipramine is a tricyclic antidepressant (TCA). Low levels of TCAs are not typically associated with an increased risk of seizures. However, high levels of TCAs can be toxic and may lead to seizures.

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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 using de-escalation techniques with a client who has become verbally aggressive with a staff member. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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