An adolescent client is being verbally abusive toward staff and ...

[Arii_bell]

An adolescent client is being verbally abusive toward staff and is refusing to comply with the unit's rules. The first action is to:
 
  1. Separate the client from other clients.
  2. Administer a PRN medication.
  3. Tell the client the behavior is unacceptable.
  4. Ignore the client as the behavior is part of the illness.

Question 2

The nurse is teaching an alcoholic patient about the importance of proper nutrition. Which of the following nutritional recommendations is appropriate for clients with alcohol dependence?
 
  1. Restrict fluid intake to decrease renal load
  2. Provide a multivitamin supplementation, including thiamine and folate
  3. Encourage a high-protein, low-carbohydrate diet to promote lean body mass
  4. Increase sodium-rich foods to increase iodine levels

[underwood14]

Answer to Question 1

1
Rationale: Expressions of anger and hostility are common on an adolescent unit. Anger expressed verbally usually takes the form of profanity. Ensuring the safety of the client and others is the primary concern. The first action would be to ensure the safety of all concerned by separating the client from the other clients. The second action would be to inform the client that the behavior, not the person, is unacceptable. The nurse must confront, not ignore, the behavior. Administering a PRN medication is not the initial action.

Answer to Question 2

2
Rationale: A multivitamin with thiamine and folate is essential for clients with alcohol dependence. Korsakoff's syndrome and Wernicke's encephalopathy are alcohol-related disorders linked to thiamine deficiency. It would not be necessary to restrict carbohydrates, increase iodine, or decrease renal load with fluid restriction.