An adult female client becomes combative with the nurse during routine medication administration. What is the nurse's primary responsibility in this situation?
a. To ensure that the client takes her medications
b. To ensure that the client is placed in physical restraints to protect the safety of the staff and other clients
c. To ensure that chemical restraints are used in the future until the client displays more appropriate and compliant behavior
d. To ensure that the client is kept safe while trying to protect staff safety and to reason with the client to try to de-escalate the combative behavior
D
The "do no harm" principle of mental health care applies to this situation. Client and staff safety are imperative. Ensuring that the client takes her medications is not of greatest concern in this situation because this most likely would cause increased combativeness. Physical restraints and chemical restraints are not reasonable options in the care of this patient.
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