The nurse is caring for a client with major depressive disorder who has been admitted to a psychiatric–mental health facility
After assessing the client, the nurse has developed a nursing diagnosis of "Risk for violence toward others related to agitation and low tolerance level." Which of the following would be an appropriate intervention for this client?
A) Encourage the client to engage in calming group activities.
B) Remove all dangerous items from the client's room.
C) Provide antianxiety medication to prevent an incident.
D) Encourage the client to act on thought that are leading to aggression.
Ans: B
Feedback:
Establishing geographic boundaries, such as room restriction or half-hall restriction, is part of ongoing monitoring. Also, clients likely will have "as-needed" medications ordered; nurses use them if aggressive or agitated behavior escalates. Other environmental approaches include reducing stimuli and opportunities for interaction with other clients in the milieu. Nurses remove all dangerous items from the client's room and monitor closely for use of any dangerous items. Nurses help clients learn to recognize what triggers violent thoughts and behaviors. They teach clients not to act on these thoughts but to leave the situation and find a staff member to talk to about them.
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