Nokea
A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN?
- A. Is attempting the physically restrain the patient.
- B. Remains at a distance of 4 feet from the client.
- C. Tells the client to go to the quiet area of the unit.
- D. Is using a loud voice to talk to the client.
Correct Answer: A
Rationale: The correct answer is A because attempting to physically restrain a client with escalating aggressive behavior can escalate the situation further, leading to potential harm to both the client and the mental health worker. Physical restraint should only be used as a last resort and under the guidance of a registered nurse to ensure safety and prevent harm. Choices B, C, and D are not immediate interventions for managing escalating aggressive behavior. Remaining at a distance of 4 feet, telling the client to go to a quiet area, or using a loud voice are not effective strategies to de-escalate the situation and may not address the root cause of the aggression.
You may also like to solve these questions
Pablo is a homeless adult who has no family connection. Pablo passed out on the street and emergency medical services took him to the hospital where he expresses a wish to die. The physician recognizes evidence of substance use problems and mental health issues and recommends inpatient treatment for Pablo. What is the rationale for this treatment choice? Select all that apply.
- A. Intermittent supervision is available in inpatient settings.
- B. He requires stabilization of multiple symptoms.
- C. He has nutritional and self-care needs.
- D. Medication adherence will be mandated.
Correct Answer: A
Rationale: The correct answer is A: Intermittent supervision is available in inpatient settings. In an inpatient treatment setting, Pablo can receive continuous monitoring and supervision, ensuring his safety and well-being. This is crucial for someone like Pablo who is homeless, has substance use issues, and expressed a wish to die. Inpatient treatment can provide a controlled environment where his physical and mental health can be closely monitored, and immediate interventions can be implemented if needed.
Incorrect choices:
B: While stabilization of multiple symptoms is important, the key factor here is the need for constant supervision, which is better provided in an inpatient setting.
C: Although nutritional and self-care needs are important, the primary concern in this case is Pablo's mental health and safety, which can be better addressed in an inpatient setting.
D: While medication adherence is important, it is not the primary reason for recommending inpatient treatment for Pablo. The need for supervision and monitoring takes precedence.
When should a nurse be most alert to the possibility of communication errors resulting in harm to the patient?
- A. Change of shift report
- B. Admission interviews
- C. One-to-one conversations with patients
- D. Conversations with patient families
Correct Answer: A
Rationale: The correct answer is A: Change of shift report. During this crucial handover period, communication errors can occur due to the transfer of information between nurses, leading to potential harm to the patient. This is when important patient details, care plans, and vital information are shared, making it a critical time for accurate and effective communication. Nurses must be vigilant to ensure clear and concise communication to prevent errors.
Summary of why the other choices are incorrect:
B: Admission interviews - While important, communication errors during admission interviews may not have as immediate impact on patient safety as during a shift change report.
C: One-to-one conversations with patients - These interactions are also important, but errors in communication may not have the same potential for harm as during a shift change report.
D: Conversations with patient families - While communication with families is vital, errors during these conversations may not always directly lead to harm as in a shift change report.
Child protective services have removed 10-year-old Christopher from his parents’ home due to neglect. Christopher reveals to the nurse that he considers the woman next door his 'nice' mom, that he loves school, and gets above average grades. The strongest explanation of this response is:
- A. Temperament
- B. Genetic factors
- C. Resilience
- D. Paradoxical effects of neglect
Correct Answer: C
Rationale: The correct answer is C: Resilience. This is because Christopher's ability to form a positive relationship with the woman next door, his love for school, and above-average grades despite experiencing neglect indicate his resilience. Resilience refers to the capacity to adapt positively in the face of adversity. Christopher's behavior shows his ability to thrive despite challenging circumstances, emphasizing his resilience. Choices A, B, and D do not fully capture Christopher's ability to overcome adversity. Temperament (A) refers to inherent personality traits, genetic factors (B) focus on biological influences, and paradoxical effects of neglect (D) do not directly address Christopher's ability to cope and thrive.
April, a 10-year-old admitted to inpatient pediatric care, has been getting more and more wound up and is losing self-control in the day room. Time-out does not appear to be an effective tool for April to engage in self-reflection. April’s mother admits to putting her in time-out up to 20 times a day. The nurse recognizes that:
- A. Time-out is an important part of April’s baseline discipline.
- B. Time-out is no longer an effective therapeutic measure.
- C. April enjoys time-out, and acts out to get some alone time.
- D. Time-out will need to be replaced with seclusion and restraint.
Correct Answer: B
Rationale: The correct answer is B: Time-out is no longer an effective therapeutic measure. In this scenario, April's escalating behavior and the ineffectiveness of time-out suggest that it is not addressing the underlying issues causing her behavior. Continuous use of time-out can lead to it losing its effectiveness and may not promote self-reflection. April's behavior worsening despite frequent use of time-out indicates the need for a different approach to address her needs.
Choices A, C, and D are incorrect because they do not address the situation at hand. Choice A assumes time-out is still effective despite evidence to the contrary. Choice C assumes April enjoys time-out, which is not supported by the information given. Choice D suggests a drastic and inappropriate measure of seclusion and restraint, which should only be used as a last resort in emergency situations.
A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the nurse to implement?
- A. Avoid recognizing the behavior.
- B. Isolate the client from other clients.
- C. Administer a PRN sedative.
- D. Escort the client to his room.
Correct Answer: D
Rationale: The correct answer is D: Escort the client to his room. Echolalia is a common symptom of schizophrenia, where the individual repeats words or phrases they hear. Escorting the client to his room provides a safe and appropriate environment for the client to engage in the behavior without bothering other clients. Avoiding recognition (choice A) may not address the behavior and could lead to escalation. Isolating the client (choice B) may be seen as punitive and could worsen the client's symptoms. Administering a sedative (choice C) should be a last resort and not the initial intervention for managing echolalia.