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.

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A reason: Staying in bed awake reinforces insomnia by associating bed with wakefulness. Sleep hygiene advises leaving bed if sleep doesn’t come soon.

Choice B reason: Low TV volume still stimulates the brain, delaying sleep onset. Screen light disrupts melatonin, worsening insomnia rather than aiding rest.

Choice C reason: Longer weekend sleep disrupts circadian rhythm, confusing sleep cycles. Consistent sleep timing is key, so this hinders nightly sleep improvement.

Choice D reason: Daily exercise boosts sleep quality by reducing stress and regulating circadian rhythm. It’s a proven insomnia remedy, promoting faster sleep onset naturally.

A. "Once you have completed a living will, it cannot be changed." B. "You should appoint a family member as your health care surrogate." C. "Your health care surrogate will make decisions on your behalf if you are unable." D. "You will need an attorney to appoint a health care surrogate."

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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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?

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