An involuntarily committed client when offered a dinner tray pushes it off the bedside table onto the floor. Which nursing intervention should a nurse implement to address this behavior?
1. Initiate forced medication protocol.
2. Help the client to explore the source of anger.
3. Ignore the act to avoid reinforcing the behavior.
4. With staff support and a show of solidarity, set firm limits on the behavior.
4
Rationale: The most appropriate nursing intervention is to set firm limits on the behavior. Pushing food onto the floor should not warrant forced medication. This intervention may be too restrictive, considering the behavior. Exploring the source of anger may be more appropriate once the client has resolved the current emotion or in a therapeutic group setting. Ignoring the act may further upset the client and is not a method of teaching appropriate behavior.
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