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This statement reflects insight and acknowledgment of the impact alcohol has had on the client’s life. It does not indicate denial but rather a level of awareness that is necessary for initiating change.

This statement shows ambivalence rather than denial. The client is skeptical about the effectiveness of reducing alcohol intake but does not reject the idea that alcohol is problematic. This may indicate a stage of contemplation in the change process.

This statement reflects guilt and recognition of the negative consequences of alcohol use on relationships. It suggests emotional awareness and a desire to change, not denial.

Methadone is used primarily for opioid withdrawal and maintenance therapy. It is not appropriate for managing alcohol withdrawal symptoms and would not address the autonomic hyperactivity or risk of seizures associated with alcohol withdrawal.

Disulfiram is used as a deterrent to alcohol consumption by causing unpleasant effects when alcohol is ingested. It is contraindicated during acute withdrawal due to its potential to worsen symptoms and its lack of efficacy in managing withdrawal-related autonomic instability.

Naltrexone is used to reduce cravings and prevent relapse in alcohol use disorder but is not indicated for acute withdrawal. Administering it during withdrawal can precipitate adverse effects and does not address the immediate physiological symptoms.

Recruiting other staff to talk the client down may escalate the situation by overwhelming the client or creating a sense of confrontation. While backup may be necessary for safety, verbal de-escalation should be initiated by one calm, trained individual to avoid confusion and maintain therapeutic rapport.

Therapeutic touch is not appropriate during episodes of aggression. Physical contact may be misinterpreted as threatening or invasive, potentially escalating the behavior. Safety protocols prioritize maintaining a safe distance and using verbal techniques.

Standing directly in front of an aggressive client may be perceived as threatening and can provoke further aggression. Staff should maintain a non-threatening posture, keep a safe distance, and avoid blocking exits to reduce the client's sense of entrapment.

While this is a critical safety concern requiring immediate intervention and documentation in the medical record, it does not constitute an incident report unless there is a breach in safety or protocol. The nurse should initiate suicide precautions and notify the provider.

This behavior is consistent with manic symptoms and may require behavioral interventions, but it does not represent a deviation from standard care or a safety breach that warrants an incident report.

Refusal to leave the room is a symptom of depression and does not represent a safety incident or deviation from care requiring an incident report. It should be addressed therapeutically through engagement and care planning.

Extended play sessions with other children may be overwhelming for a child with autism spectrum disorder, especially if they struggle with social cues and emotional expression. Structured, individualized interventions are more effective in promoting emotional development.

Guided imagery requires abstract thinking and verbal processing, which may be challenging for children with autism. These children often benefit more from concrete, sensory-based interventions that align with their cognitive and communication styles.

Progressive muscle relaxation can be helpful for anxiety but may not directly address emotional expression. It also requires understanding and following multi-step instructions, which may be difficult depending on the child’s developmental level.

While discussing the pros and cons may seem informative, it risks influencing the client's decision and may be perceived as coercive. The nurse's role is to support autonomous decision-making, not to persuade or dissuade the client. This approach may also violate ethical principles of informed consent if the client feels pressured.

Telling the client it is too late to cancel the procedure is incorrect and unethical. Clients have the right to withdraw consent at any time before a procedure. This response disregards the principle of autonomy and may constitute a violation of patient rights.

Contacting the next of kin for permission is inappropriate unless the client has been deemed legally incompetent. In this case, the client is expressing a clear and rational decision, indicating capacity. Seeking permission from others undermines the client’s autonomy and legal rights.

Asking about a support system is important for long-term safety planning, but it is not the priority in an acute crisis. The nurse must first assess the immediacy and severity of the suicide risk before exploring protective factors.

Inquiring about past suicide attempts is part of a comprehensive suicide risk assessment, but it is not the first step. The priority is to determine current intent and whether the client has a specific plan, which indicates imminent danger.

A psychosocial history provides valuable context but is not the immediate priority in a crisis. It does not directly assess the client’s current risk of self-harm or suicide.

Using an app to monitor relapse cues demonstrates proactive behavior and self-awareness. It supports recovery by helping the client recognize and manage triggers, making it a protective factor rather than a barrier.

Moving into a halfway house with residential treatment provides structure, peer support, and access to professional care. This environment is conducive to recovery and reduces the risk of relapse.

Identifying potential triggers is a strength, not a barrier. It reflects insight and readiness to implement coping strategies. Recognizing triggers is a key component of relapse prevention planning.

Recommending that the friend contact the hospital indirectly implies that the teacher may be admitted, which breaches confidentiality. It also shifts responsibility inappropriately and may lead to further privacy violations.

This statement is misleading. Nurses cannot discuss client information even with family members unless the client has provided explicit consent. It also implies that the teacher is indeed hospitalized, which violates confidentiality.

Suggesting the friend contact the high school is irrelevant and does not address the confidentiality issue. It may also perpetuate gossip or misinformation, which is unprofessional.