Pediatric Nursing Q 164
A 15-year-old boy was hospitalized in a psychiatric unit because he initiates frequent fights with peers. Which implementation is most appropriate?
A. Anticipate and neutralize potentially explosive situations
B. Ignore minor infractions of rules against fighting
C. Isolate the adolescent from contact with peers
D. Talk to the adolescent each time fighting occurs
Correct Answer: A. Anticipate and neutralize potentially explosive situations.
The nurse is responsible for maintaining a safe environment; therefore, it would be appropriate to observe for signs that an explosive situation is developing and intervene to neutralize the situation, thereby preventing a fight.
Option B: Ignoring minor infractions of rules against fighting in a psychiatric unit would not be a minor infraction and should not be ignored. This could lead to unsafe situations that could escalate out of control.
Option C: Isolation and seclusion are methods of intervention that can be used as a last resort after less restrictive means are employed. Opponents of seclusion have based their arguments on a concern for the rights of mental patients and a dedication to treat patients in the least restrictive environment.
Option D: Talking to the adolescent each time a fight occurs does not indicate that the nurse is setting and enforcing clear, consistent rules. The nurse needs to maintain safety and would not allow fighting to occur if it could be avoided.