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A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach will the nurse take?
- A. Call a staff member to escort the client to his room.
- B. Tell the client to talk to his healthcare provider about his privileges.
- C. Remind the client of the unit rules.
- D. Ignore the client's inappropriate behavior.
Correct Answer: C
Rationale: (C) is the correct approach in this situation as it reinforces unit rules, setting clear boundaries and expectations. By reminding the client of the unit rules, the nurse is helping to maintain a safe and structured environment within the drug rehabilitation unit. (A) is unnecessary since the client's behavior does not warrant immediate physical intervention. (B) is not ideal because the client's privileges have already been explained, and suggesting he speak to his healthcare provider may not address the immediate issue. (D) is not appropriate as addressing inappropriate behavior is essential in a therapeutic setting.
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What is the best initial action for the nurse to take with a manic depressive male client who becomes loud and verbally aggressive towards a nurse?
- A. Have the staff escort the client to his room.
- B. Tell the client that his behavior will be recorded in his record.
- C. Redirect the client by asking him to engage in a game with peers.
- D. Review the medication record for an antipsychotic drug.
Correct Answer: C
Rationale: In dealing with a manic depressive client who is being verbally aggressive, the best initial action for the nurse is to redirect the client by engaging him in a more constructive activity, such as playing card games with peers. This approach can help de-escalate the situation, shift the client's focus positively, and provide a distraction from the current behavior. Having the staff escort the client to his room may escalate the situation further. Threatening to record the behavior in his record is not likely to be effective in managing the immediate situation. Reviewing the medication record for an antipsychotic drug is important but would not be the best initial action in this scenario when the client is being verbally aggressive.
A client with schizophrenia is experiencing auditory hallucinations. What is the most appropriate nursing intervention?
- A. Encourage the client to ignore the voices.
- B. Ask the client what the voices are saying.
- C. Distract the client with a new activity.
- D. Tell the client that the voices are not real.
Correct Answer: B
Rationale: Asking the client what the voices are saying is the most appropriate intervention as it helps the nurse assess the content of the hallucinations and the potential risk they may pose. Encouraging the client to ignore the voices (Choice A) may not address the underlying issue or provide valuable information for the nurse. Distracting the client with a new activity (Choice C) may temporarily divert attention but does not address the hallucinations. Telling the client that the voices are not real (Choice D) may invalidate the client's experience and can lead to distrust in the therapeutic relationship.
A male client turns over a table in the dayroom of a psychiatric unit and threatens to throw a chair at another client. Which action is most important for the nurse to implement?
- A. Calmly approach the client and remove the chair from the client.
- B. Obtain staff assistance to help diffuse the escalating situation.
- C. Offer feedback about the client's behavior.
- D. Summon the hospital security guards as a 'show of force.'
Correct Answer: B
Rationale: In a situation where a client is displaying aggressive behavior, the most important action for the nurse to implement is to obtain staff assistance to help diffuse the escalating situation. This approach ensures the safety of all individuals involved and prevents the situation from escalating further. Calmly approaching the client and removing the chair directly could agitate the client further and pose a risk to the nurse. Offering feedback about the client's behavior may not address the immediate safety concerns. Summoning hospital security guards as a 'show of force' should be a last resort after other de-escalation attempts have failed, as it may further provoke the client.
During the manic phase of bipolar disorder, what is the priority nursing intervention for a female client who has not slept for the past 48 hours, is hyperactive, talkative, and engaging in risky behaviors?
- A. Encourage the client to participate in a quiet activity.
- B. Provide a safe environment and limit stimuli.
- C. Administer a sedative to help the client sleep.
- D. Discuss the consequences of her risky behaviors.
Correct Answer: B
Rationale: The correct priority nursing intervention for a female client in the manic phase of bipolar disorder, who has not slept for 48 hours, is hyperactive, talkative, and engaging in risky behaviors, is to provide a safe environment and limit stimuli. This approach is crucial to prevent harm to the client and others. Encouraging a quiet activity (Choice A) may not effectively address the need for safety during the manic phase. Administering a sedative (Choice C) should be done under the guidance of a healthcare provider and does not address the immediate safety concerns. Discussing consequences of risky behaviors (Choice D) may not be effective during the manic phase when the client's judgment is impaired.
An adolescent who attempted suicide with a drug overdose arrives in the emergency department with an empty 30-tablet bottle of acetaminophen (Tylenol). Which action should the nurse implement?
- A. Administer acetylcysteine (Mucomyst).
- B. Monitor cardiac rhythm for flat T waves.
- C. Check both serum AST and ALT levels.
- D. Prepare to administer Syrup of Ipecac.
Correct Answer: A
Rationale: The correct action for the nurse to implement is to administer acetylcysteine (Mucomyst). Acetylcysteine is the antidote for acetaminophen overdose and should be administered promptly to prevent liver damage. Monitoring cardiac rhythm for flat T waves (Choice B) is not specific to acetaminophen overdose and is more related to cardiac conditions. Checking serum AST and ALT levels (Choice C) may be done later but is not the initial priority in this situation. Similarly, preparing to administer Syrup of Ipecac (Choice D) is not recommended anymore in cases of overdose as it can cause more harm.