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Referring the client to a support group is an important intervention for long-term recovery and emotional support. Support groups provide validation, coping strategies, and community resources. However, this is not the immediate priority in the emergency department setting, where safety and mandatory reporting requirements must come first.

Teaching stress-reduction techniques can help the client manage anxiety and emotional distress associated with intimate partner violence. While beneficial, this intervention is not urgent in the acute care setting. Stress management is a secondary measure that should be addressed after immediate safety and legal obligations are met.

Placing the client in a private area to ensure safety is appropriate and supports the client’s immediate physical and emotional security. However, while important, it is not the priority compared to mandatory reporting. Safety measures should accompany reporting but do not replace the legal and ethical responsibility to follow protocol.

Rhinorrhea is not a typical finding in alcohol withdrawal. It is more commonly associated with opioid withdrawal due to autonomic hyperactivity.

Hypotension is not characteristic of alcohol withdrawal. Instead, clients often experience hypertension and tachycardia due to autonomic nervous system hyperactivity.

Hyperglycemia is not a direct manifestation of alcohol withdrawal. While alcohol use can affect glucose metabolism, withdrawal symptoms are primarily neurological and autonomic, not metabolic.

Families with rigid rules typically do not make decisions based on compromise. Instead, decisions are imposed by authority figures, often without input from other members. This lack of flexibility prevents healthy negotiation and collaboration, making compromise unlikely in such family systems.

Older children taking over parenting roles for younger children is more characteristic of families with role confusion or dysfunction, not necessarily rigid rule systems. In rigid families, roles are strictly defined and enforced, leaving little room for children to assume parental responsibilities.

Minimal communication is not the defining feature of rigid families. While communication may be controlled or authoritarian, it is not necessarily absent. Rigid families often have structured communication patterns, but the issue lies in the lack of flexibility rather than minimal communication.

Administering medication is an intervention that may be necessary if the client escalates further, but it is not the first action. Medication should be used after attempting less restrictive measures and ensuring safety.

Seclusion is a restrictive intervention that should only be used as a last resort when the client poses imminent danger to themselves or others. It is not the first step in managing escalating anger.

Walking with the client to release energy can be a helpful de-escalation technique, but it requires that the environment is safe and that the client is not at immediate risk of harming themselves or others. Before attempting this, the nurse must ensure safety precautions are in place.

Dependent behaviors are not consistent with improvement in antisocial personality disorder. This disorder is characterized by manipulation, disregard for rules, and lack of empathy, not dependency. Developing dependent behaviors would indicate maladaptive coping rather than therapeutic progress.

Manipulating others to increase self-worth is a hallmark maladaptive behavior of antisocial personality disorder. Continued manipulation reflects persistence of the disorder’s core features and does not indicate improvement. Effective treatment aims to reduce manipulation and promote healthier coping strategies.

Verbalizing a sense of personal identity is more aligned with improvement in borderline personality disorder, where identity disturbance is a central feature. While self-awareness is beneficial, it is not the primary therapeutic goal in antisocial personality disorder. The focus is on reducing harmful behaviors and improving social functioning, making this option less relevant.

Teaching relaxation techniques is helpful for managing stress but is not the priority in a crisis situation. Before teaching coping strategies, the nurse must assess immediate safety risks.

Advising the client to maintain usual routines can provide stability, but it is not the first action. In a crisis, the nurse must prioritize safety and assess for risk of harm before focusing on routine maintenance.

Encouraging transparency in communication is beneficial for therapeutic rapport and problem-solving. However, it does not address immediate safety concerns. This step should follow after assessing for self-harm risk.

Telling the client that requests are not granted until case management approves is incorrect. Case management does not have the authority to override a competent client’s decision to leave. This response would be misleading and could be considered coercive, violating the client’s right to autonomy. Nurses must respect the client’s legal rights and avoid imposing unnecessary barriers to discharge.

Placing the client in restraints is inappropriate and unethical in this scenario. Restraints are only indicated when a client poses an immediate risk of harm to themselves or others, and even then, they must be used as a last resort with strict legal and ethical guidelines. Using restraints to prevent a competent client from leaving would constitute false imprisonment and a violation of patient rights. It could also cause psychological trauma and worsen the client’s mental health condition.

Notifying the client’s family members is not the correct immediate action. While family involvement can be beneficial in treatment planning, the nurse must prioritize the client’s autonomy and confidentiality. Unless the client consents or there is a legal requirement (such as the client being a minor), family members cannot be notified without violating privacy laws. The nurse’s responsibility is to document the client’s decision and ensure proper AMA procedures are followed, not to involve family without consent.

Waxy flexibility is a psychomotor symptom often associated with catatonia in schizophrenia, not a medication adverse effect. It refers to the client maintaining a position for an extended period when placed in that position by another person. This is a manifestation of the illness itself, not a side effect of thioridazine.

Incongruent affect refers to a mismatch between emotional expression and verbal content, such as smiling while describing something sad. This is a symptom of schizophrenia rather than an adverse effect of thioridazine. Documenting this would be appropriate for psychiatric assessment but not as a medication-related complication.

Anhedonia, or the inability to experience pleasure, is a negative symptom of schizophrenia itself. It is not considered an adverse effect of thioridazine. While antipsychotics may not improve negative symptoms, they do not cause anhedonia as a side effect.