An adolescent client is being verbally abusive toward staff and is refusing to comply with the unit's rules. The first action is to:
1. Separate the client from other clients.
2. Administer a PRN medication.
3. Tell the client the behavior is unacceptable.
4. Ignore the client as the behavior is part of the illness.
1
Rationale: Expressions of anger and hostility are common on an adolescent unit. Anger expressed verbally usually takes the form of profanity. Ensuring the safety of the client and others is the primary concern. The first action would be to ensure the safety of all concerned by separating the client from the other clients. The second action would be to inform the client that the behavior, not the person, is unacceptable. The nurse must confront, not ignore, the behavior. Administering a PRN medication is not the initial action.
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