An adolescent client was recently admitted to the psychiatric unit because of impulsivity and acting-out behavior at school. The nurse should initially implement which nursing action?
A. Redirect the client to activities to decrease stress.
B. Explain the unit rules and consequences of breaking the rules.
C. Place the client on close observation to insure a trusting relationship.
D. Administer an anti-anxiety medication.
ANS: B
It is important for the nurse to initially explain the unit rules and consequences of breaking the rules. It is imperative that consequences of rule infractions are explained early in treatment to avoid misunderstanding and manipulation.
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