The nurse is providing care to a client who is diagnosed with paranoid schizophrenia.The client is threatening the staff and believes the staff is trying to harm him.When the nurse enters the client's room,the client is agitated,and attempts to slap the nurse.The nurse gets assistance from other staff members and restrains the client.Which nursing action is the priority at this time?

Question

Quizplus · Accepted Answer

The priority nursing action at this time is to notify the health care provider of the need to see the client within the hour. This allows the provider to assess the client's condition and determine the appropriate course of action. Requesting a psychiatric referral is important, but it may not be an immediate priority in this situation. Padding the side rails is a safety measure, but it does not address the client's immediate needs. Obtaining consent for use of restraints is important, but it may not be possible or feasible in an emergency situation where the client is threatening harm.

The Nurse Is Providing Care to a Client Who Is