While in the dayroom, one of the patients becomes very agitated and begins to threaten to harm the other patients and is directing violence at the other patients and staff. What is the most ap-propriate nursing implementation?
a. Decrease the stimuli and use restraints if all other measures fail.
b. Offer to call the physician and ask another staff member to call security.
c. Remove harmful objects and try to per-form relaxation exercises with the patient.
d. Restrain the patient and do not allow him or her to eat or drink anything by mouth.
A
Because the patient is threatening to harm others, decreasing stimuli will be helpful to decrease the behavior and, if everything else fails, restraints will be needed. Restraints should be applied according to current policy. Patients who are being restrained need to have frequent checks and their nutritional and elimination needs monitored.
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