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A nurse in a mental health facility is interacting with a client who is angry and becoming increasingly aggressive. Which of the following actions should the nurse take?
- A. Move the client to a private area so the conversation will not be disturbed.
- B. Use clarification to determine what the client is feeling.
- C. Speak to the client using an authoritative voice.
- D. Maintain constant eye contact with the client.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Moving the client to a private area ensures privacy, reduces stimulation, and promotes a sense of safety, which can help de-escalate the situation. It also prevents the client from feeling embarrassed or judged by others, allowing for more open communication. This approach prioritizes the client's emotional well-being and safety.
Summary:
B: While clarification is important for understanding the client's emotions, it may not be the most immediate action needed in a potentially escalating situation.
C: Speaking authoritatively may further agitate the client and escalate the situation.
D: Maintaining constant eye contact could be perceived as confrontational and may escalate aggression.
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A nurse is caring for a client who has delusional behavior and states, "I can't go to group therapy today. I am expecting a high-level official to visit me." The nurse responds, "I understand, but it is time for group therapy, and we expect everyone to attend. Let's walk over together.” For which of the following reasons is the nurse's response considered therapeutic?
- A. It clearly articulates what is expected of the client.
- B. It demonstrates empathy towards the delusion.
- C. It sets limits on the client's manipulative behavior.
- D. It uses reflection when talking with the client.
Correct Answer: A
Rationale: The correct answer is A because the nurse's response clearly articulates what is expected of the client, which helps maintain structure and promote accountability. By stating the expectation for the client to attend group therapy, the nurse is establishing boundaries and reinforcing the therapeutic environment. This approach helps the client understand the importance of participating in treatment activities.
Choice B is incorrect because empathy towards the delusion may validate the client's false beliefs, which is not therapeutic in this context. Choice C is incorrect as the response is not primarily aimed at setting limits on manipulative behavior but rather at promoting participation in therapy. Choice D is incorrect as the response does not involve reflection but rather straightforward communication of expectations.
A nurse is admitting a client who has multiple injuries following a motor vehicle crash. Shortly after admission, the client's partner arrives. He is distraught and blames himself for the accident. Which of the following responses should the nurse make?
- A. "Do not worry about that. Your wife will be fine."
- B. "I think you should calm down a little before you see your partner."
- C. "Why do you think the crash is your fault?"
- D. "Tell me more about your feelings about what happened to your partner."
Correct Answer: D
Rationale: Encouraging the partner to express emotions helps with emotional processing and coping.
A nurse is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific individual. Which of the following statements by the newly licensed nurse indicates understanding?
- A. "I need to make sure that the potential victim is warned."
- B. "I need to keep the information confidential due to the client's right to privacy."
- C. "I can only discuss the client’s threats with a court order."
- D. "I should verbally report this information to the psychiatrist."
Correct Answer: A
Rationale: The correct answer is A. When a client threatens harm to a specific individual, the appropriate action is to ensure the safety of the potential victim by warning them. This is crucial in preventing harm and fulfilling the nurse's duty to protect life. Option B is incorrect because in cases of potential harm, confidentiality can be breached to protect others. Option C is incorrect as waiting for a court order delays necessary action. Option D is incorrect as immediate action should be taken rather than waiting for a psychiatrist's involvement.
A nurse is discussing comorbidities associated with eating disorders with a newly admitted client. Which of the following conditions should the nurse include in the discussion? (Select all that apply.)
- A. Anxiety
- B. Obsessive-compulsive disorder
- C. Schizophrenia
- D. Breathing-related sleep disorder
- E. Depression
Correct Answer: A, B, E
Rationale: Anxiety, OCD, and depression frequently co-occur with eating disorders.
A nurse is sitting in the day room at an acute care mental health facility with a group of clients who are watching television. Suddenly, one of the clients jumps up screaming and runs out of the room. Which of the following actions should the nurse take?
- A. Ask the group what they think about the client’s behavior.
- B. Follow the client to determine the cause of the behavior.
- C. Ignore the incident because it is an attention-seeking behavior.
- D. Stay with the group and ask another client to check on the situation.
Correct Answer: B
Rationale: The correct answer is B: Follow the client to determine the cause of the behavior. This is the best course of action as the nurse should prioritize the safety and well-being of the client who exhibited distress. By following the client, the nurse can assess the situation, provide immediate assistance if needed, and ensure the client's safety. This proactive approach allows the nurse to address any potential risks or triggers that may have caused the client to react in such a manner.
Choice A is incorrect because seeking the group's opinion may waste time and delay necessary intervention. Choice C is incorrect as ignoring the incident could lead to a potentially dangerous situation being overlooked. Choice D is also incorrect as asking another client to check on the situation may not ensure the client's safety and well-being. The best approach is for the nurse to directly assess the client's needs and respond accordingly.