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A nurse is reinforcing behavior management techniques with the parent of a school-age child who has conduct disorder. Which of the following statements by the parent indicates an understanding of the redirection technique?
- A. I should use role-playing to enhance new behavioral skills.
- B. I should move closer to my child when they are agitated.
- C. I should ignore attention-seeking behaviors.
- D. I should re-engage my child in an appropriate activity.
Correct Answer: D
Rationale: Re-engaging the child in an appropriate activity is a key part of the redirection technique. It helps divert the child's attention away from the undesired behavior and encourages positive behavior, showing the parent understands this approach.
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A nurse is caring for a client who is experiencing a situational crisis. Which of the following actions should the nurse take first?
- A. Assist with a client referral for social services.
- B. Identify if the client has thoughts of self-harm.
- C. Reinforce teaching on the client's use of coping skills.
- D. Encourage the client to use personal support systems.
Correct Answer: B
Rationale: Identifying thoughts of self-harm is crucial for immediate safety and risk management, making it the priority action. This ensures the client’s well-being is secured before addressing other needs.
A nurse is reinforcing teaching with the caregiver of a client who has Alzheimer's disease. The caregiver reports that the client awakens at night and wanders. Which of the following strategies should the nurse suggest?
- A. Place a lock at the top of doors leading outside.
- B. Use light restraints while the client is in bed.
- C. Administer an antianxiety medication before bedtime.
- D. Encourage the client to nap during the day.
Correct Answer: A
Rationale: Placing a lock at the top of doors helps prevent the client from wandering outside, ensuring safety. This is a practical, non-restrictive measure to manage nighttime wandering in Alzheimer’s.
A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states
- A. That looks like a snake
- B. and I won't let it take all of my blood.' Which of the following responses should the nurse make?
- C. I don’t see a snake, but that must be scary for you.
- D. I’m using a syringe to obtain your blood, not a snake.
- E. Your provider requires this blood specimen.
- F. You must be mistaken.
Correct Answer: A
Rationale: Acknowledging the client's fear and providing reassurance without confirming the hallucination helps build trust and reduce anxiety. This empathetic response supports the client’s emotional state.
A nurse is caring for a client who has dementia and is experiencing an increased number of falls. Which of the following actions should the nurse take?
- A. Request a consult with recreational therapy.
- B. Lower the window shade in the client's room.
- C. Place the client in a room close to the nurses' station.
- D. Obtain a PRN prescription for a vest restraint.
Correct Answer: C
Rationale: Placing the client near the nurses' station allows for closer monitoring and quicker intervention, which can help prevent falls. This is a practical, non-restrictive measure to enhance safety.
A nurse is collecting data from an adult client in an outpatient mental health clinic. The nurse should identify which of the following events as a potential cause of a maturational crisis?
- A. Loss of job.
- B. Motor-vehicle crash.
- C. Divorce.
- D. A child leaving for college.
Correct Answer: D
Rationale: A child leaving for college represents a maturational crisis, tied to normal developmental transitions that cause stress. Unlike situational crises like job loss or divorce, it reflects life stage changes.