While in the dayroom, one of the patients becomes very agitated and begins to threaten to harm the other patients and is directing violence at the other patients and staff. Appropriate nursing implementations include:
1. decreasing stimuli and using restraints if all other measures fail.
2. offering to call the physician and telling other staff to call security.
3. removing harmful objects and trying to do relaxation exercises with the patient.
4. restraining the patient and keeping him NPO.
1
Because the patient is threatening to harm others, decreasing stimuli will be helpful to de-crease the behavior and, if everything else fails, restraints will be needed. Restraints should be applied according to current policy. Patients who are being restrained need to have fre-quent checks and their nutritional and elimination needs monitored.
PTS: 1 DIF: Cognitive Level: Synthesis REF: 1259
OBJ: 7 TOP: Nursing Implementations for Manic Episodes
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
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