A nurse is working with a client who becomes combative and threatens other clients and staff. Which of the following actions should the nurse take?
Stand in front of the client to block them from others in the room.
Apply restraints according to the facility's standing order.
Ensure there are enough staff members available for assistance.
Obtain a PRN prescription for restraints from the provider.
The Correct Answer is C
Choice A reason: Standing in front risks escalation and injury; de-escalation needs space. Safety protocol prioritizes staff positioning away from a combative client’s reach.
Choice B reason: Standing orders for restraints vary; immediate application skips assessment. Ensuring staff support first allows safer, assessed intervention per guidelines.
Choice C reason: Adequate staff ensures safe de-escalation or restraint if needed. It’s the priority, reducing risk to all in a combative situation effectively.
Choice D reason: PRN restraint orders follow de-escalation attempts; staff availability precedes this. Immediate safety via numbers is critical before seeking prescriptions here.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: A primary care provider focuses on medical care, not financial aid coordination. Scientifically, they diagnose and treat, lacking the resource linkage role needed for formula access, making this less effective for socioeconomic support postpartum.
Choice B reason: A nutritionist advises on diet, not funding solutions for formula. Scientifically, their expertise is nutritional planning, not social services, misaligning with the client’s economic barrier, requiring broader assistance beyond dietary guidance.
Choice C reason: A pediatric nurse practitioner manages child health, not financial resources. Scientifically, their scope is clinical, not case coordination, making them less equipped to address affordability compared to a role focused on systemic support.
Choice D reason: A case manager connects clients to resources like WIC for formula, addressing financial need. Scientifically, this role bridges socioeconomic gaps, aligning with evidence-based interprofessional care to ensure infant nutrition via community programs.
Correct Answer is C
Explanation
Choice A reason: Living wills can be updated anytime, not fixed. This misinformation contradicts legal flexibility, key for clients to understand in directives.
Choice B reason: Surrogates needn’t be family; any trusted person qualifies. Mandating family limits choice, misrepresenting the broad options in directive planning.
Choice C reason: A surrogate decides when the client can’t, per advance directives. This accurately informs about proxy roles, essential for incapacity planning.
Choice D reason: Attorneys aren’t required; forms suffice legally in most states. This overcomplicates surrogacy, deterring clients from completing directives unnecessarily.
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