After observing a client with bipolar disorder on the mental health unit, the nurse determines that the client is at an acute risk for violence. Which of the following would be the most appropriate intervention?
A) Ask the client to sit alone and write a letter.
B) Restrict the client to his room until he calms down.
C) Encourage him to participate in an activity with other clients.
D) Tell the client that if he is violent, he will be sent home.
Ans: B
Feedback:
If clients are determined to be at risk for violence, establishing geographic boundaries, such as room or half-hall restriction, is part of ongoing monitoring. Other environmental approaches include reducing stimuli and opportunities for interaction with other clients. Nurses remove all dangerous items from client rooms and monitor closely for use of any dangerous items. A pen or pencil that is used to write a letter can be a dangerous object.
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