An ICU nurse has just assisted the physician in placing a central line in a client. Over the past few days the client's son has been increasingly verbally abusive to the nursing staff

Question

The unit secretary tells the nurse that the son is at the nurse's station demanding to see the client. Which action by the nurse is most important? 1. Remove the central line tray from the room.
2. Inform the son regarding the client's condition.
3. Ignore the son as he enters the client's room.
4. Limit the son's visitation.

Answer 1

1
Rationale 1: Health care staff should be aware when and where to store medical instruments that may be used as weapons.
Rationale 2: The son should be informed of the client's condition, but with the history and the escalation of his behavior the nurse should take action to protect staff.
Rationale 3: Ignoring the son may cause the violent behavior to escalate.
Rationale 4: Limiting visitation may cause the violent behavior to escalate.
Global Rationale: