A nurse on a mental health unit observes a client yelling at another client. Which of the following actions should the nurse take first?

State expectations for the client's behavior.

Request security personnel restrain the client.

Place the client in seclusion.

Debrief staff members about the conflict.

Answer and Explanation

The Correct Answer is A

The correct answer is Choice A.

Choice A rationale: By stating expectations for the client’s behavior, the nurse is addressing the immediate situation and setting clear boundaries. This intervention allows the nurse to assertively communicate with the client, reminding them of appropriate behavior and potentially diffusing the situation 1.

Choice B rationale: Requesting security personnel to restrain the client should be a last resort, used only when the client poses a significant risk to themselves or others and all other de-escalation techniques have failed. Restraint can be traumatic and has potential physical and psychological risks.

Choice C rationale: Placing the client in seclusion is another measure that should be used sparingly and only when necessary for the safety of the client or others. It’s important to try less restrictive measures first, such as verbal de-escalation techniques or offering a quiet, private space where the client can regain control.

Choice D rationale: Debriefing staff members about the conflict is an important step, but it should not be the first action. The immediate priority is to ensure the safety of all clients and to de-escalate the situation.

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Correct Answer is D

Explanation

Herpes simplex is primarily transmitted through direct contact with the skin or mucous membranes of an infected individual. Contact precautions are designed to prevent the spread of microorganisms that are transmitted by direct contact or indirect contact with contaminated surfaces. These precautions include wearing gloves and a gown when entering the client's room, ensuring proper hand hygiene, and using dedicated equipment for the client.

Droplet precautions are used for infections that are transmitted through respiratory droplets generated by coughing, sneezing, or talking, such as influenza or pertussis.

Airborne precautions are used for infections that are transmitted by smaller droplet nuclei that can remain suspended in the air for longer periods, such as tuberculosis or measles.

Protective environment is a specialized isolation precaution used for clients with compromised immune systems, such as those undergoing stem cell transplantation, and involves strict control of the environment to reduce the risk of acquiring infections.

A. "I will carry my baby to the nursery." B. "I can take my baby to the lobby to visit family." C. "I can remove my security band to give it to a family member." D. "I will have an identification band that matches the one my baby wears."

Correct Answer is D

Explanation

This statement shows that the mother understands the importance of having matching identification bands for herself and her baby. In healthcare facilities, identification bands are used as a security measure to ensure that newborns are correctly matched with their parents or caregivers. Having matching identification bands helps to prevent any mix-ups or unauthorized individuals from taking the baby. It demonstrates that the mother is aware of the security protocol and will actively participate in ensuring her baby's safety.

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A nurse on a mental health unit observes a client yelling at another client. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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