A licensed practical/vocational nurse (LP/VN) is caring for an older adult client on the geriatric psychiatric unit
The nurse is in a hurry and enters the client's room to provide the morning care, change his dressing, and get him dressed and walk him in the hall with assistance of one. The nurse has cared for him for days, and the client always spoke in a soft voice and was pleasant, but today the client started yelling and swinging at the nurse. Which is the best first action for the nurse to provide?
A) Place a physical restraint and obtain an order from the physician.
B) Get back from the client's swinging distance and speak calmly.
C) Talk loudly because the client has problems hearing.
D) Administer the as needed sedation.
Ans: B
Feedback:
The nurse should get out of swinging distance and speak in calm, reassuring voice and slow down actions toward the client because the client perceives the sudden hurried actions of the nurse as a threat and is acting out to protect himself. Using medication restraint is unnecessary as the best first action because behavior management should be tried before medications. Physical restraint at this point of time would increase the client's agitation and anger. Speaking loudly would also increase the client's behaviors, and there is no evidence that the client has difficulty hearing since he spoke in a soft voice in the past.
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