Rn HESI Management NGN

Rn HESI Management NGN ( 48 Questions)

While walking down the hallway, the nurse finds a female client yelling, swinging her hands, and pushing a male visitor away from her hospital bed. Which intervention should the nurse implement first?



Correct Answer: D

Choice A rationale: The nurse does not need to determine who is assigned the care of  the client, as this is not relevant to the immediate situation. 

Choice B rationale: The nurse should not enter the room and quietly observe the  interaction, as this would delay the intervention and put the client and the visitor at risk.

Choice C rationale: The nurse should not notify the hospital security department  immediately, as this would also delay the intervention and may escalate the situation.

Choice D rationale: The nurse should prioritize the safety of the client and the visitor,  and intervene to stop the potential violence. The nurse should instruct the visitor to  leave the room immediately, and then assess the client's condition and provide  appropriate care. 




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