At 11:00 p.m. a client diagnosed with antisocial personality disorder demands to phone a lawyer to file for a divorce. Unit rules state that no phone calls are permitted after 10:00 p.m. Which nursing response is most appropriate?
1. "Go ahead and use the phone. I know this pending divorce is stressful."
2. "You know better than to break the rules. I'm surprised at you."
3. "It is after the 10:00 p.m. phone curfew. You will be able to call tomorrow."
4. "A divorce shouldn't be considered until you have had a good night's sleep."
3
Rationale: The most appropriate response by the staff is to restate the unit rules in a calm, assertive manner. The nurse can encourage the client to verbalize frustration while maintaining an accepting attitude. The nurse may also help the client to identify the true source of frustration.
You might also like to view...
The nurse is caring for a patient in intensive care unit receiving IV lorazepam (Ativan) to reduce anxiety related to mechanical ventilation. While injecting the medication the nurse notes a decrease in blood pressure and bradycardia
What is the nurse's priority action? A) Discontinue drug administration. B) Give the IV drug more slowly. C) Notify the patient's health care provider. D) Document the reaction to the drug.
A patient has been scheduled for cardioversion in the treatment of a tachyarrhythmia but is unclear about the particulars of the procedure after signing the necessary informed consent. How can the nurse best explain this procedure to the patient?
A) "Cardioversion will essentially 'reset' the cells in your heart that control the electrical activity." B) "The essence of cardioversion is the destruction of some of the misfiring cells that are throwing off your heart's rhythm." C) "Cardioversion will provide an electrical signal that will boost the strength of your heart's electrical activity." D) "Cardioversion replaces your heart's self-conduction with an electrical signal that is provided artificially."
The main objective of the medical management of glaucoma is to:
a. correct visual abnormalities c. reduce intraocular pressure b. prevent postsurgical infection d. relieve pain
A 17-year-old girl with spina bifida is helping her mother prepare for her younger brother's birthday party. After blowing up a balloon the girl develops erythemia and itching around her mouth. This is likely due to which of the following?
A) A developing cold sore B) A food allergy C) A latex allergy D) Facial eczema