Author Question: A client diagnosed with brief psychotic disorder is pacing the milieu and occasionally punches the ... (Read 133 times)

KimWrice · **on:** Jul 19, 2018

A client diagnosed with brief psychotic disorder is pacing the milieu and occasionally punches the wall. Which should be the initial nursing action?

A. Assertively instruct the client to stop punching the wall.
B. Encourage the client to write down feelings in a journal.C. With the help of staff, initiate seclusion protocol.
D. Ensure adequate physical space between the nurse and the client.

Question 2

On an inpatient psychiatric unit, a restrained 16-year-old client continues to verbally lash out and threatens to abuse staff and kill self when released.

To meet Joint Commission standards, at what time should a nurse expect the physician to renew the client's restraint order? A. Within 1 hour of the original restraint order
B. Within 2 hours of the original restraint order
C. Within 3 hours of the original restraint order
D. Within 4 hours of the original restraint order

ttt030911 · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

D
To maintain a safe environment, it is important to initially assure that there is adequate physical space between the nurse and the client. Violence can be related to increased contact and decreased defensible space.

Answer to Question 2

B
The Joint Commission (JCAHO) requires that a physician or a licensed independent practitioner reissue a new order for restraints every 4 hours for adults, every 2 hours for adolescents, and every 1 hour for children.