A mental health nurse has been assigned to a client diagnosed with schizophrenia. Upon entering the room, the client yells, "Get out of here, you little brat! You're bigger than my kid sister, who is horrible!"
The initial action of the nurse would include which of the following?
A) Sit down on the client's bed and initiate a conversation.
B) Run out of the client's room yelling, "I need some help here!"
C) Tell the client that her behavior is not acceptable and will not be tolerated.
D) Slowly back out of the client's room, and summon for help.
Ans: D
Nursing staff and clinicians are experienced in assessing the client's potential for violence and have specific protocols to utilize when this occurs. The nurse should be familiar with these protocols. The nurse should neither try to confront the client nor create a disruption. Initiating any type of conversation when the client is confrontational would not be appropriate. Running from the room and yelling may cause increased agitation in this client. Telling the client that her behavior is unacceptable does not resolve the current situation. The most appropriate nursing action in this situation would be to leave the client's room and summon help.
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