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A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse:
A. Should apply full restraints until the behavior is under control
B. Should allow other clients to observe the acting out so that they can learn from the experience
C. Must use the least restrictive measure possible to control the behavior
D. Should put the client in seclusion until he promises to behave appropriately
Answer: C
(A) This answer is correct. Least restrictive measures should always be attempted before a client is placed in seclusion or restraints. The nurse should first try a calm verbal approach, suggest a quiet room, or request that the client take "time-out" before placing the client in seclusion, givingmedication as necessary, or restraining.
(B) This answer is incorrect. A calm verbal approach or requesting that a client go to his room should be attempted before restraining. (C) This answer is incorrect. Restraints should be applied only after all other measures fail to control the behavior. (D) This answer is incorrect. Other clients should be removed from the area. It is often very anxiety producing for other clients to see a peer out of control. It could also lead to mass acting- out behaviors.


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