A nurse on a mental health unit is assisting with the care of a client.
The nurse is continuing to assist with the care of the client. Select the four actions the nurse should take.
Ask the provider for a PRN prescription for restraints.
Administer diazepam when the client exhibits anxiousness.
Place the client in a room near the nurse's station.
Determine if the client is experiencing command hallucinations.
Establish clear limits for expected behaviors.
Correct Answer : B,C,D,E
A. Ask the provider for a PRN prescription for restraints: Restraints should only be used as a last resort when there is an imminent risk of harm to the client or others. In this situation, it is essential to first attempt to manage the client's anxiety and behavior through de-escalation strategies and appropriate interventions.
B. Administer diazepam when the client exhibits anxiousness: Diazepam can help manage anxiety and agitation, which is crucial for the client's safety and comfort. Monitoring for signs of anxiety allows for timely intervention with the prescribed medication.
C. Place the client in a room near the nurse's station: Keeping the client close to the nurse's station allows for increased monitoring and ensures that staff can respond quickly if the client's behavior escalates. This helps maintain safety for both the client and others on the unit.
D. Determine if the client is experiencing command hallucinations: Assessing for command hallucinations is important, especially given the client's recent aggressive behavior. Understanding the presence of such hallucinations can guide the treatment plan and safety measures.
E. Establish clear limits for expected behaviors: Setting clear expectations for behavior helps the client understand acceptable conduct and promotes a safer environment. This can be particularly important for clients with paranoid personality disorder who may struggle with interpersonal relationships.
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Related Questions
Correct Answer is D
Explanation
A. The majority of people who have been incarcerated at state prisons are treated for a serious mental illness: While many incarcerated individuals do have serious mental illnesses (SMIs), a significant number do not receive adequate treatment while in prison. This statement is not accurate as a majority of those incarcerated do not receive proper mental health care.
B. People who have SMIs and have been incarcerated are less likely to be victimized: Individuals with SMIs may actually be at greater risk of victimization while incarcerated due to their vulnerability. This statement does not accurately reflect the reality of their experiences.
C. People who have been incarcerated rarely experience inadequate treatment while in prison: Many individuals with SMIs do not receive adequate treatment while incarcerated, which can exacerbate their conditions and contribute to challenges upon release.
D. People who have SMIs and have been incarcerated face a greater risk of discontinuing treatment and relapsing. Individuals with SMIs often struggle with continuity of care after release, leading to higher rates of treatment discontinuation and relapse. The transition from prison to community care can be difficult, resulting in gaps in treatment and support.
Correct Answer is B
Explanation
A. They do not care that they lost their job and their partner: This statement reflects a potential lack of insight or awareness regarding the impact of their behavior on their life and relationships. However, this attitude may also stem from denial, which is common in individuals with addictive behaviors. Even if the client appears indifferent, their actions indicate a compulsive engagement in gaming and gambling, highlighting the disconnect between their awareness of consequences and their inability to change the behavior.
B. They compulsively act on the urge to continue internet gaming and gambling even though they suffered negative consequences: This behavior is characteristic of non-substance addiction. It emphasizes the compulsive nature of the client's engagement in these activities, regardless of the significant negative impacts on their life, such as job loss, financial difficulties, and relationship issues.
C. They are depressed over their current life situation: While depression may be a concurrent issue, it does not specifically reflect the compulsive behaviors associated with non-substance addiction. The focus should be on the actions that indicate addiction rather than emotional responses.
D. They filed for bankruptcy because of their debts and job loss: Filing for bankruptcy is a consequence of the client's behavior, but it does not directly indicate the compulsive nature of their gaming and gambling habits. The focus on the behavior itself is more relevant to understanding the addiction.
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