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 B

Explanation

A. Keep the client hospitalized until there is no longer a threat

Nurses do not have the authority to unilaterally detain clients in a hospital. This decision is typically made by a physician or a legal authority, especially in the context of a medical-surgical unit where mental health professionals may need to be involved.Keeping a client hospitalized without proper legal procedures and mental health evaluation could lead to legal repercussions for unlawful detainment.

B. Ensure the client's ex-partner is notified of the threat

This option involves notifying the potential victim about the threat made by the client. While it's important to ensure the safety of others, the nurse's legal duty primarily lies with protecting the confidentiality of the client's information. Without consent from the client or a legal obligation, such as mandatory reporting laws for imminent harm, the nurse cannot disclose the threat to the ex-partner.

C. Ask a friend or family member to monitor the client

While involving family or friends might provide support, it is not a sufficient or appropriate response to a threat of harm. It does not address the immediate risk posed to the ex-partner and may not comply with legal obligations.

D. Transfer the client to a mental health facility

Transferring the client to a mental health facility for further evaluation and treatment might be necessary, but it must be done through appropriate medical and legal channels. It addresses the need for a thorough mental health assessment and ensures that the client receives the necessary care.

A. "Has a family member indicated that you should cut down on your drinking?” B. “Have you had a glass of wine in the last week?” C. “Do you drink alcohol with your friends?” D. "Do you enjoy drinking alcohol?”

Correct Answer is A

Explanation

A. "Has a family member indicated that you should cut down on your drinking?”: This question assesses whether there have been any external concerns or criticisms related to the client's alcohol consumption, which is a common feature in alcohol use disorder.

B. “Have you had a glass of wine in the last week?”: While this question assesses recent alcohol consumption, it does not specifically address problematic drinking patterns or consequences associated with alcohol use disorder.

C. “Do you drink alcohol with your friends?”: This question addresses social drinking behavior but does not specifically focus on the potential for alcohol use disorder or problematic drinking patterns.

D. "Do you enjoy drinking alcohol?”: While enjoyment of alcohol may be relevant to the overall assessment, it does not specifically address problematic drinking patterns or consequences associated with alcohol use disorder.

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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 on a medical-surgical unit is caring for a client who tells the nurse about their intentions to harm an ex-partner. Which of the following actions is a legal duty of the nurse?

Correct Answer is B

Explanation

A nurse is caring for a client who reports a history of frequent alcohol consumption. Which of the following questions should the nurse ask when screening for alcohol use disorder?

Correct Answer is A

Explanation

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