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A client lost control of his behavior, broke a window, and made verbal threats to staff and other clients. The client was placed in mechanical restraints. Which statement should the nurse make to explain the use of restraints to the client?
- A. The length of time you'll be in restraints is undetermined.
- B. The staff will monitor your behavior closely.
- C. This is what happens when you lose control.
- D. This is a means of keeping you and others safe.
Correct Answer: D
Rationale: Explaining restraints as a safety measure clarifies their purpose without implying punishment, unlike vague or punitive statements.
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A client suddenly jumps up from the chair and begins yelling and cursing at the nurse. Which would be the best response by the nurse?
- A. I can see that you need attention, you should calmly ask for what you want
- B. I don't want to hear that kind of language, don't ever do that again.
- C. I will limit your smoking privileges if you can't control yourself
- D. You seem angry. Tell me more about how you're feeling
Correct Answer: D
Rationale: Acknowledging the client's anger and encouraging verbal expression promotes de-escalation, unlike punitive responses or assumptions about needs.
The client identifies anger management as a problem. What is the next step in planning therapeutic interactions?
- A. Give the client a variety of choices on how to express anger.
- B. Give the client permission to be angry.
- C. Point out the senselessness of anger.
- D. Tell the client not to be angry all the time.
Correct Answer: B
Rationale: Permitting the client to view anger as a normal emotion reduces guilt and sets the stage for learning expression techniques, unlike dismissing or minimizing anger.
A client is clenching his fists and yelling at another client on the unit. He appears to be close to losing control of his anger. Which of the following actions by the nurse is appropriate at this time?
- A. Clear others out of the immediate area.
- B. Prepare a PRN sedative.
- C. Tell the client to stop and take a time-out.
- D. Alert the security department of an impending aggressive outburst.
Correct Answer: C
Rationale: Directing the client to take a time-out during the escalation phase is a least restrictive intervention to regain control, prioritizing de-escalation over sedatives or security.
Which is most likely to be the subject of an aggressive attack from a client with mental illness?
- A. Other people
- B. The client
- C. Animals
- D. Objects
Correct Answer: B
Rationale: Clients with mental illness are more likely to harm themselves than others, animals, or objects due to internal distress or self-directed aggression.
Anger management is likely to be included in the care of clients with which of the following psychiatric diagnoses?
- A. Alzheimer's dementia
- B. Schizophrenia
- C. Anorexia nervosa
- D. Acute alcohol intoxication
- E. Generalized anxiety disorder
Correct Answer: A,B,D
Rationale: Clients with Alzheimer's dementia, schizophrenia, or acute alcohol intoxication may exhibit aggression due to cognitive impairments or delusions, requiring anger management, unlike anorexia or anxiety.