A client admitted to the mental health unit starts to shout and scream at the nurse. Which approach is best for the nurse to take?
Tell the client they are out of control.
Stay quietly with the client.
Distract the client by offering finger foods.
Ignore the client's acting out behavior.
The Correct Answer is B
Choice A rationale: Telling the client they are out of control may escalate the situation and provoke further aggression. It is not a therapeutic or de-escalation technique.
Choice B rationale: Staying quietly with the client is a calm and non-confrontational approach. It allows the client to express emotions while conveying a supportive presence.
Choice C rationale: Distracting the client by offering finger foods may not be appropriate during a shouting episode, as it may be perceived as dismissive of the client's feelings or concerns.
Choice D rationale: Ignoring the client's acting-out behavior is not the best option. The nurse should acknowledge the client's emotions and provide support rather than ignoring the distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: Initiating an exercise program may be a helpful intervention, but the primary goal for this client following a drug overdose and romantic relationship issues is to return to the previous level of functioning.
Choice B rationale: Identifying positive personal traits is a positive goal but may not be the most immediate priority for this client.
Choice C rationale: Returning to the previous level of functioning is the primary goal for hospitalization. This goal involves restoring the client's ability to manage daily life and cope with stressors.
Choice D rationale: Describing what is needed in a romantic relationship is important, but the immediate focus is on the client's overall functioning and safety.
Correct Answer is C
Explanation
Choice A rationale: "If your partner is abusing you, I need to ask these questions" may be too direct and could potentially make the client feel pressured or uncomfortable. The nurse should emphasize the routine nature of the screening.
Choice B rationale: "The healthcare provider needs to know if you are experiencing any domestic abuse" is correct but may sound directive. Emphasizing the routine nature of the screening helps to normalize the process.
Choice C rationale: "All clients are screened for domestic abuse because it is common in our society" is the best choice. It normalizes the screening process, reducing stigma and encouraging disclosure.
Choice D rationale: "State law mandates that I ask if you are a victim of domestic violence" may make the client feel compelled to answer due to legal reasons, potentially affecting the validity of the response. Emphasizing routine screening is a more patient centered approach.
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