A female nurse walks into the hospital room of a 50-year-old male client, for the first time. The client is recuperating from knee surgery. The male client speaks little English and there are bed rails in place. The client has no pyjama bottoms on and he throws the sheet back to expose himself and then reaches out to grab the nurse. What should the nurse's immediate response be?

Question

Quizplus · Accepted Answer

The nurse should first ensure her own safety by moving out of the client's reach. She should then assess the situation and determine if the client's behavior is a result of confusion or delirium, or if he is attempting to engage in inappropriate behavior. If necessary, she can then call for assistance from a colleague or medical practitioner. Leaving the room immediately (option D) without assessing the situation or attempting to address the behavior is not appropriate. Option A does not address the immediate safety concern and may provide an opportunity for the client to continue inappropriate behavior. Option C should only be considered after all other options have been exhausted, and only if the client's behavior poses a serious risk to himself or others.

A Female Nurse Walks into the Hospital Room of a 50-Year-Old