A client is brought to a busy emergency department by their spouse due to erratic behavior and expressions of despair.

If the client shrugs their shoulders when asked by the triage registered nurse if they feel suicidal now, what nursing responsibility is the practical nurse expected to be assigned?

Ask the client to make a verbal contract to not harm self.

Return the client to the waiting room with the spouse.

Document that the client is not currently suicidal.

Place the client in an ideal situation with one-on-one observation.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Asking the client to make a verbal contract to not harm themselves is a common strategy used in suicide prevention. However, it is not the primary responsibility of the practical nurse in this scenario.
Choice B rationale
Returning the client to the waiting room with the spouse is not the most appropriate action. The client’s safety is the top priority, and they should be closely monitored due to their erratic behavior and expressions of despair.
Choice C rationale
Documenting that the client is not currently suicidal is important, but it is not the primary responsibility of the practical nurse in this scenario. The client’s non-verbal cues (shrugging their shoulders) suggest they may be at risk.
Choice D rationale
The primary responsibility of the practical nurse in this scenario would be to place the client in an ideal situation with one-on-one observation. This ensures the client’s safety and allows for immediate intervention if necessary.

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Correct Answer is B

Explanation

Choice A rationale
While teaching the client techniques for coping with the mother’s anger might be helpful, it does not address the root cause of the problem. The mother’s anger and inappropriate responses could be due to frustration from not being able to hear properly.
Choice B rationale
The mother’s behavior of not responding when her back is turned and becoming increasingly angry could be signs of hearing loss. A hearing evaluation would help determine if this is the case and appropriate interventions can be put in place.
Choice C rationale
Telling the client that it appears the mother has a hearing loss is not the best intervention because it is based on assumption without any professional evaluation. It is important to have a professional evaluation before making such conclusions.
Choice D rationale
Informing the client to ignore the behavior and treat the mother with love does not address the potential issue of hearing loss. Ignoring the problem does not solve it and could lead to further frustration and misunderstanding.

A. The patient interpreted the UAP’s behavior as potentially harmful. B. Older adult patients often demonstrate exaggerations of behaviors used earlier in life. C. The patient learned violent behavior by watching other patients act out. D. Crowding in skilled nursing facilities increases an individual’s tendency toward violence.

Correct Answer is A

Explanation

Choice A rationale
The patient likely interpreted the UAP’s behavior as potentially harmful. This is a common reaction in confused older adults, especially when they are awakened unexpectedly. The patient may not have fully understood the situation and reacted out of fear or confusion.
Choice B rationale
While it’s true that older adults can sometimes demonstrate exaggerations of behaviors used earlier in life, there’s no information in the scenario to suggest this is the case.
Choice C rationale
There’s no evidence to suggest that the patient learned violent behavior by watching other patients act out. It’s more likely that the patient reacted out of fear or confusion.
Choice D rationale
While crowding can increase stress and agitation in some individuals, there’s no information in the scenario to suggest that this is a factor in the patient’s behavior.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client reports to the nurse that her elderly mother has become increasingly angry and responds inappropriately to conversations within the past few months. She notes that her mother does not respond when the mother’s back is turned. What is the best intervention for the nurse?

Correct Answer is B

Explanation

A confused older adult patient in a skilled nursing facility was asleep when unlicensed assistive personnel (UAP) entered the room quietly and touched the bed to see if it was wet. The patient awakened and hit the UAP in the face. Which statement best explains the patient’s action?

Correct Answer is A

Explanation

A patient with cognitive impairment, who has been a widow for 30 years, is desperately trying to leave the facility, stating, “I have to go home to cook dinner before my husband gets home from work.”. How should the nurse intervene using validation therapy?

An adult patient assaulted another patient and was subsequently restrained. One hour later, which statement by the restrained patient requires the nurse’s immediate attention?

Which of the following actions is the best example of aggressive behavior?

What are the goals of therapeutic communication?

In a medical-surgical unit, the nurse is monitoring several patients. Which patient does the nurse identify as being at the highest risk for developing delirium?

What expected outcomes should the nurse document for a client diagnosed with a depressive disorder? (Select all that apply)

During the assessment phase of the nursing process, data collection takes place. What methods does the nurse employ to gather data? (Select all that apply.)