A nurse is facilitating a group therapy session at a community mental health center. A client diagnosed with antisocial personality disorder repeatedly talks over others, makes insulting remarks about a peer's clothing, and attempts to dominate the discussion. What is the most appropriate initial nursing action?
- Clearly inform the client that the insulting comments are unacceptable and state the consequence if the behavior continues.Answer
- BAsk the client to explain why they are feeling frustrated and need to criticize the other participants.
- CInstruct a nursing assistant to sit beside the client and intervene if further disruptions occur.
- DImmediately dismiss the client from the session and require them to remain in a quiet room.
Answer
The most appropriate initial action is to clearly inform the client that the insulting comments are unacceptable and state the consequence if the behavior continues.
When managing a client exhibiting boundary-testing and disruptive behavior, the priority nursing intervention is to set clear, firm, and consistent limits. This involves identifying the specific unacceptable behavior and outlining the consequences if it continues. This approach maintains a safe and therapeutic milieu for all group members using the least restrictive effective method.
Step-by-Step Solution
Key Concept
Limit-setting and least restrictive behavioral interventions