A manic client is pacing the halls of the inpatient unit and ...

[fox]

A manic client is pacing the halls of the inpatient unit and making disruptive comments to the other clients.
 
  The nurse overhears the client say, I know people, so you better treat me with respect Which of the following therapeutic nursing interventions would the nurse implement first? 1. Notify security that this client is escalating out of control and the client needs to be escorted to the client's room.
  2. Tell the client that the nurse would like to give a PRN injection because the behavior is disrupting others.
  3. Approach the client and say in firm voice, That was inappropriate. Go to your room immediately.
  4. Address the client and say in a calm voice, The staff will work hard to make sure you receive proper respect here. Let's go over here and talk.

Question 2

A client is being admitted to the inpatient psychiatric unit. Which actions would be appropriate for the nurse to assess the client's risk of violence? Standard Text: Select all that apply.
 
  1. Wait to assess the client's risk of violence once the psychiatric symptoms have stabilized.
  2. Assess history of psychotic illness as this is the most important predictor of violence potential.
  3. Ask the client, What is the most violent thing you have ever done?
  4. Review the client's past records and get information from the client's family.
  5. Avoid discussing the client's past history of violence as this could provoke the client.

[xiazhe]

Answer to Question 1

4
Rationale: Reassuring the client that the client will be respected validates the client's need for respect and provides an opportunity to further assess the client's ability to establish control and to respond to verbal cues. It is a bit premature to notify security until the nurse has determined that the client is nonresponsive to redirection, and this does not reinforce the element of respect in the nurse-client relationship. Telling the client that the behavior is inappropriate is paternalistic and the command sounds punitive, directly the opposite of what the client is demanding, which could provoke a negative response from the client. When used as a method for de-escalation, medication should first be offered as an option rather than a demand and the rationale should be based on the client's needs, not others.

Answer to Question 2

3,4
Rationale: Wait to assess the client's risk of violence once the psychiatric symptoms have stabilized. Do not wait to assess the client's risk of violence, this should be done as soon as possible so that a plan can be implemented to reduce the client's risk of violent behavior.

[fox]

Excellent

[juliaf]

TYSM