A client yells and grabs the nurse’s arm when the nurse won't give another dose of IV hydromorphone 30 minutes after the first. Which is the most appropriate response?

"Let go" and call for help.

Explanation

• The best action is to call for assistance while informing the client that their action is unacceptable and that they need to release their hold. When a client responds with violence to a nurse, it is important for the nurse to try and de-escalate the situation by remaining calm and to simultaneously seek assistance. 

• When the nurse has been touched or grabbed, his or her instinct may be to react defensively. Self-defense is an appropriate option only if the client is an imminent threat of further violence. In most circumstances, the appropriate response is to calmly but firmly request the patient to let go while waiting for assistance. If the nurse tries to forcibly get out of the grip before help has arrived, the situation could escalate.

• It is unwise to inform the angry client about assault charges when you are alone with the client. The goal is to de-escalate the situation.

• It is unwise to lie to the client and suggest that the drug will be provided. 
 

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