Question

A nurse on a mental health unit observed the client who has acute mania hit another client. Which of the following actions should the nurse take first

a.Call the provider to obtain an immediate prescription for restraint.Calling the provider for an immediate prescription for restraint is an appropriate action. However, this is not the first action the nurse should take.
b.Prepare to administer benzodiazepine IM.An IM injection of a benzodiazepine might be indicated for this client. However, this is not the first action the nurse should take.
c.Call for a team of staff members to help with the situation.MY ANSWERThe greatest risk is injury to the client and others. Therefore, the first action the nurse should take is to call for assistance to prevent further injury to themselves or others.
d.Check the client who has was hit for injuries.Once the nurse and other clients are safe, the nurse should assess the client who was hit for injuries to determine if medical intervention is needed. However, this is not the first action the nurse should take.

Answer 1

The correct option is c.

A nurse's first action after observing a client with acute mania hit another client should be to call for assistance to ensure safety. Subsequent actions include checking the injured client for any injuries and considering further interventions like restraint or medication.

Step-by-step explanation:

The question is related to the appropriate immediate actions for a nurse to take following an incident of violence in a mental health unit. The first action the nurse should take is to call for a team of staff members to help with the situation, as the immediate priority is to ensure the safety of everyone present and to prevent further injury.

This is essential in managing a volatile situation and provides the opportunity for the nurse to then administer further necessary interventions, such as obtaining a prescription for restraint or administering medication.

Once the situation is under control and safety is established, the nurse should then check the injured client for injuries to determine the need for medical care.