A nurse in a psychiatric care unit finds that a client with psychosis has become violent and has struck another patient in the unit. What action should the nurse take in this case?
A) Do not restrain the client, as it is equivalent to false imprisonment.
B) Restrain the client, as he is harmful to the other patients.
C) Do not restrain the client, as it is equivalent to battery.
D) Inform the physician and complete a comprehensive assessment.
B
Feedback:
The nurse should restrain the client because he is potentially harmful to other patients in the psychiatric care unit. Restraints should be used as a last resort and their use should be justified. Unnecessary restraining can lead to allegations of false imprisonment and battery; both are not applicable in this case, however. The nurse should inform the physician about the client, but sometimes it may not be logical to wait for orders to restrain a violent client.
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