"Try to realize how fortunate you are that our society doesn't let the group escalate to more punitive measures after your crimes against children."
"Are you saying that you understand people are afraid for their children but that you feel you are being unfairly treated?"
"It's sad for you, but when children are hurt as you hurt them, people want you identified and isolated"
"You seem angry, but you must understand that your neighbors are frightened because of your serious crimes against children."
“Those feelings will go away once your medication really takes effect.”
“I know what you mean; everyone gets that way when they are depressed.”
“Have you talked to anyone specifically about what is bothering you?”
“You sound very unhappy. Are you thinking of harming yourself?”
“I don't believe that, and I really don’t think you do either.”
“I’m sure you have someone if you think hard enough.”
“It sounds as though you are feeling all alone right now.”
“That doesn’t sound like the real you talking!”
Have the client put on a hospital gown and remove the client’s clothing from the room.
Request that a friend of the client remain with the client at all times.
Suggest placing the client in a seclusion room where all potentially dangerous articles are removed.
Stay with the client at all times.
Examine the neck area and assess the airway
Encourage the client to talk about the experience
Administer an anxiolytic medication as prescribed at once.
Obtain a detailed history of events leading to the attempt
"It is very, very hard to get over these types of feelings after being raped."
"It’s hard, but try to keep a sense of perspective. After all, it’s been a while since the rape occurred.”
"What do you think you should do to reduce the likelihood that you will be raped again?"
"Tell me more about what happened, which causes you to feel like the rape just occurred."
Helping the client relax
Giving the client something to drink
Giving the client oxygen by nasal cannula
Taking the client's vital signs
Identifying situations that precipitate compulsive behavior and encourage the client to verbalize his concerns and feelings.
Allow the client to perform the ritualistic behavior, but set limits on behaviors that might interfere with the client's physical well-being.
Recognize and reinforce positive, nonritualistic behaviors
Administer tranquilizers such as diazepam to sedate the client when the client's actions jeopardize the safety of others.
He is unhappy about his family's request for emergency medical care. The nurse should tell the client his family only wants what's best for him.
He needs encouragement and the nurse should provide reassurance that the client has been brought to a very good health care facility and that the doctors will soon be able to make him feel better.
The client is depressed and at risk for suicide, the nurse should stay with him.
The client has the right to refuse medical treatment and the nurse should leave the room.
Poor dietary choices
Lack of exercise and poor diet
Inadequate dietary intake and dehydration
Psychomotor retardation and side effects of medication
Restrict the daughter's socializing time with her friends
Restrict the amount of chocolate and caffeine products in the home
Keep her daughter out of school until she can adjust to the school environment
Consider taking time from work to help her daughter readjust to being at home
The client's outlandish behavior and inappropriate dress
The client's grandiose delusions of being a royal descendent of King Arthur
The client's constant incessant talking that includes sexual innuendoes and teasing the staff
The client's nonstop activity and poor nutritional intake
Approach the client in the hallway and insist that she go into the room
Confront the client on the inappropriateness of her behavior and offer her a time out.
Quietly approach the client, escort her to her room and assist her in getting dressed
Ask the other clients to ignore her behavior: she will eventually return to her room.
A paint-by-number activity
A brown bag lunch and book review
Deep breathing and progressive relaxation exercises
Put the client in a quiet room
Remain with the client
Teach the client deep breathing
Encourage the client to talk about her feelings and concerns.
Communicate expected behaviors to the client
Ensure that the client knows that he or she is not in charge of the nursing unit.
Assist the client in developing means of setting limits on personal behaviors.
Follow through about the consequences of behavior in a nonpunitive manner.
Be clear with the client about the consequences of exceeding limits set regarding behavior.
Disturbed sleep pattern related to inability to sleep and sensitivity to environmental noise
Noncompliance with medication and treatment regimen related to health beliefs
Imbalanced nutrition: Less than body requirements related to constant activity and increased metabolic demand
Risk for Electrolyte Imbalance related to inadequate fluid intake and lithium therapy for bipolar disorder
Hopelessness related to feelings of loss of control and need for lifelong treatment with mood stabilizing medications
Anxiety related to inability to recall important information
Notice unusual behavior patterns, such as a father bringing children in for medical care without the mother being present.
Assess all members of the family unit, especially the children, for signs of physical injury.
The nurse should ask directly if abuse is occurring
The nurse should schedule a follow-up appointment to validate concerns