What would be the nurse's appropriate action based on the analysis of this situation? The manic client announces to everyone in the dayroom that a stripper is coming to perform this evening. When the nurse firmly states that this will not happen, the manic client becomes verbally abusive and threatens physical violence to the nurse.
A. Orient the client to time, person, and place. B. Tell the client that the behavior is not appropriate. C. Escort the manic client to her room, with assistance. D. Tell the client that smoking privileges are revoked for 24 hours.
Of course the pt needs to be removed from the dayroom, but would you not advise the pt the behavior is inappropriate immediately after, even during rant. At no point in the question does it say this has already happened, just the stripper is not coming.
Escort the manic client to her room, with assistance.
The client is at risk for injury to self and others and therefore should be escorted out of the dayroom. Antipsychotic medications are useful to manage the manic client. Hyperactive and agitated behavior usually responds to haloperidol (Haldol). Option 4 may increase the agitation that already exists in this client. Orientation will not halt the behavior. Telling the client that the behavior is not appropriate already has been attempted by the nurse. Test-Taking Strategy: Use the process of elimination and Maslows Hierarchy of Needs theory to answer the question. Look for the option that promotes safety of the client, other clients, and staff. If you had difficulty with this question, review the appropriate interventions when dealing with a manic client.