A nurse is caring for a client who has tested positive for amphetamines and is experiencing paranoia. The client has a history of physical violence. Which intervention should the nurse implement at this time to prevent the client from becoming violent?

Question

A nurse is caring for a client who has tested positive for amphetamines and is experiencing paranoia.  The client has a history of physical violence.  Which intervention should the nurse implement at this time to prevent the client from becoming violent?

Quizplus · Accepted Answer

Violence in the health care setting poses a safety risk to clients, staff, and visitors. It also decreases the quality of care that a violent client receives due to avoidant and fearful behaviors by staff. Risk factors for violence include altered level of consciousness, substance abuse, emotional stress, and behavioral/psychiatric disorders. Nursing interventions that help prevent violence include using clear, thorough communication (Option B); encouraging active participation in care; promoting a low-stimulation environment; and providing comfort through pharmacological and nonpharmacological methods. The nurse should demonstrate undivided attention to the client (eg, facing the client, unhurried body language, calm tone). (Option A) Chemical (eg, lorazepam) and physical restraints should be used only as last resorts to keep clients and others safe. It is not appropriate to use restraints to prevent escalation to violence. (Option C) Placing the client near the nurses' station may increase anxiety due to the noise and activity in that area. The client should be closely monitored, but this is not an effective intervention for preventing violence. (Option D) The presence of security personnel does not prevent violence and may cause increased client anxiety. The nurse should consider other interventions (eg, effective communication) to prevent violence. Educational objective: Violence is a safety concern for all in the health care setting. Nurses must identify those at risk for violent behavior and use clear, thorough communication to prevent violence. The nurse should provide undivided attention to the client while explaining all activities of care in a calm tone.

A Nurse Is Caring for a Client Who Has Tested