Mental Health Question #5

Question

The nurse is caring for an alcoholic client who underwent a splenectomy following a drunk-driving vehicle accident. Alcohol withdrawal occurs and the client becomes combative, confused, and is trying to get out of bed. What is the most appropriate action for the nurse to take?

Answers

  1. Call the hospital’s violence code team.
    • Rationale:
  2. Call a meeting conference meeting at the nurse’s station.
    • Rationale:
  3. Call the family to sit with the client.
    • Rationale:
  4. Obtain a physician’s order for short-term mechanical restraints.
    • Rationale:

Overview

Explanation

Use of restraints must be weighed carefully with the risks of injury by using the restraints against risk for not using restraints. Physical restraints may be used for clients who are aggressive, violent, and harm to self or others. Call to the hospital’s code team may occur if the situation progresses to a crisis stage. The code team can assist with the restraints, but the question does not infer the behavior is affecting others. The Nurse and Staff do not need to call a meeting during an escalating event and since the client is confused and combative, calling family into the room may heighten the violence.

Learning Outcomes

Test Taking Tip

Video Rationale