A client who told everyone on the unit that he is a famous author is at the nursing station arguing with the nurse who has limited the phone calls for today.
The client has been repeatedly calling a large bookstore nearby asking to speak to a publisher, and the store's manager has refused to come to the phone. The last phone call resulted in some loud obscenities from the client. The nurse believes that some boundaries need to be set. Is the nurse's action reasonable? A) Yes, because the client's actions are related to his delusion.
B) Yes, because the nurse wants to protect the hospital from a nuisance lawsuit brought by the bookstore.
C) Yes, the nurse is using judgment to prevent the client's agitation from escalating.
D) No, because restricting phone use is a curtailment of the client's civil rights.
Question 2
A nurse is teaching a client with hallucinations some self-help strategies. The client says that the voices bother him most when he is at work washing dishes at Hamburger Haven. Which strategies would be least helpful for him?
A) Encourage him to try earplugs.
B) Loudly tell the voices to stop or to go away..
C) Encourage him to try listening to music with headphones.
D) Talk to him about using his PRN medication.
NANDA international nursing diagnosis 2
Effects of nursing rounds on patient safety
Nursing history for abdominal assessment
Nursing Interventions According to Stage of Severity for Suicide Risk
Measuring the client’s weight with a standard platform scale
Nursing: A Concept-Based Approach to Learning, Volume II, 3rd Edition