A client is agitated and pacing in the hall near the nurses' station and swearing loudly. What response is the best for the registered nurse to provide?
Select one:
Others are being distracted; Please, quiet down and go to your room.
You seem pretty upset. Tell me about it
Please go to your room to get control of yourself.
What’s going on? Be quiet.
The Correct Answer is B
This response acknowledges the client's distress and opens the opportunity for the client to express their feelings and concerns. It also demonstrates empathy and a willingness to listen, which can help deescalate the situation and build trust between the nurse and client.
Option a ("Others are being distracted; Please, quiet down and go to your room") is dismissive of the client's feelings and may further escalate the situation.
Option c ("Please go to your room to get control of yourself") is directive and may be perceived as confrontational, potentially increasing the client's agitation.
Option d ("What's going on? Be quiet") is insensitive and dismissive of the client's distress and may further agitate the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Involuntary hospitalization for mental illness is typically reserved for situations where an individual poses an immediate danger to themselves or others due to a severe mental illness. In option A, the individual is experiencing command hallucinations, which are often a symptom of a severe mental illness such as schizophrenia. The fact that they want to hurt their neighbor is a clear indication that they pose a danger to others and require emergency intervention.
Option B may indicate a mental illness such as schizophrenia or bipolar disorder, but it does not necessarily pose an immediate danger to the individual or others.
Option C may indicate a relapse in addiction, but again, it does not necessarily pose an immediate danger to the individual or others.
Option D may indicate a need for follow-up and intervention, but it does not indicate an immediate danger to the individual or others.
Correct Answer is C
Explanation
Manipulative behavior is not acceptable in any situation, and it is important for the nurse to set clear boundaries and expectations with the client. Allowing manipulation can enable the client's behavior and reinforce it. Avoiding discussing past or present manipulative behaviors with the client may not effectively address the issue and could potentially worsen the behavior. Bargaining with the client can also reinforce manipulative behavior.
Therefore, instituting consequences for manipulative behavior is the most appropriate intervention to include in the plan of care. This could involve setting clear limits on what is acceptable behavior and consistently enforcing consequences when those limits are exceeded. The consequences should be communicated clearly to the client, and the nurse should work with the client to identify more appropriate ways to communicate their needs and concerns.
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