When a nurse enters the room, the client states, "He has a gun," and points toward a male visitor. The nurse does not see a gun. What should the nurse do?
1. #the visitor regarding the statement.
2. Contact security.
3. Call for another nurse to assist in confronting the visitor.
4. Notify the client's physician.
2
Rationale 1: The nurse should not make any attempt to question the visitor or to appear aggressive in any manner.
Rationale 2: The nurse should contact security immediately and should implement any other strategies outlined in the security plan.
Rationale 3: The nurse should not confront the visitor or allow any other nonsecurity employee to do so.
Rationale 4: The client's physician will not be able to offer any assistance during the immediate incident.
Global Rationale:
You might also like to view...
The staff members in a long-term care facility have noted a decline in cognitive function in one of the residents; however, each time the resident is given the Short Portable Mental Status Ques-tionnaire (SPMSQ), the score does not change
What action by the nursing manager is best? a. Provide in-service education on using this tool. b. Conduct the assessment him- or herself c. Switch to a different screening tool d. Determine that no changes have occurred.
A male infant is born with the urethral meatus opening on the underside of the penis. When providing information to the parents, what is the correct terminology to use for this condition?
A) Phimosis B) Hypospadias C) Epispadias D) Paraphimosis
Which of the following is the initial intervention for the nurse to complete when caring for a client with mental illness?
A) Offering sound advice on the problem B) Limit-setting in the relationship C) Providing a friendly atmosphere D) Establishing trust and rapport
The nurse is caring for a client. What action should the nurse take to determine this client's teaching needs?
1. Speak in plain language 2. Ask if the client understands 3. Select 5th grade reading material 4. Use questions beginning with "why"