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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

a.Spending equal time with clients regardless of their insurance status: This situation relates more to justice, ensuring fairness and equality in client care, rather than fidelity.

b.This scenario represents the principle of veracity, which involves providing truthful and accurate information to clients. It ensures that clients are fully informed and can give informed consent regarding their treatment.

c.Respecting the decision of clients to refuse to participate in group therapy:Fidelityrefers to the duty to be loyal, faithful, and keep promises. It involves maintaining trust and being reliable in our interactions with clients. This situation aligns with fidelity. Respecting a client's decision to refuse treatment, even if it's something the nurse believes would be beneficial, demonstrates fidelity to the client's autonomy and their right to make choices about their care.

d.This situation reflects the principle of beneficence, which involves taking actions to benefit clients, including continuing education to improve client care and nonmaleficence (avoiding harm).

A. The client states that he has developed sudden hearing loss B. The client states that his partner will not visit because they are too busy with their job C. The client yells obscenities at the nurse D. The client stomps his fees and throws objects of the bedside table

Correct Answer is D

Explanation

A. The client states that he has developed sudden hearing loss: This could potentially be an example of somatization, where psychological distress is expressed through physical symptoms. However, sudden hearing loss alone might not specifically indicate regression.

B. The client states that his partner will not visit because they are too busy with their job: This statement does not directly suggest regression. It appears to be an explanation or justification for the partner's behavior.

C. The client yells obscenities at the nurse: Yelling obscenities could indicate frustration or anger, but it does not necessarily suggest regression. It could be a response to the current situation rather than a regressive behavior.

D. The client stomps his feet and throws objects off the bedside table: This behavior could indicate regression. Stomping feet and throwing objects are more characteristic of childish or immature behavior, which suggests a regression to an earlier stage of emotional development.

View Question and Answer

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

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 charge nurse in a community mental health clinic is discussing ethical concepts of client care with a newly licensed nurse. The charge nurse should use which of the following situations as an example of fidelity?

Correct Answer is C

Explanation

Correct Answer is D

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?

A nurse is assessing an older adult client's ability to make a successful role transition to widowhood following the death of her partner. Which of the following factors should the nurse include in the assessment? (Select all that apply.)

A nurse is reviewing the medical records of a group of clients. For which of the following clients should the nurse recommend a referral for assertive community treatment (ACT)?

A nurse is caring for a client who is taking a tricyclic antidepressant. For which of the following findings should the nurse monitor as an adverse effect of tricyclic antidepressants?

A nurse is assessing a client who reports using cocaine 1 hr ago. Which of the following findings should the nurse expect?

A nurse is conducting a child maltreatment screening of a family who has a toddler. Which of the following findings should the nurse identify as an indicator of possible child neglect?

A home health nurse is caring for a client who reports feeling tired and being unable to grocery shop. Which of the following responses by the nurse is an example of therapeutic communication?

A nurse is caring for a client who has dementia and insists a doll is her infant child. Which of the following behavioral management techniques should the nurse use when interacting with the client?