A client is manipulative with staff and disruptive in the milieu. Although the client is not demonstrating behaviors that are a threat to self or others, they are refusing all medications. Which action by the nurse is most appropriate?

Inform the client that a family member will be called to see if they can help.

Prepare discharge paperwork since the client is refusing assistance.

Set clear boundaries for behavior and allow the refusal of medication.

Inform the client that without the medications, their mental status will not improve.

Answer and Explanation

The Correct Answer is C

When dealing with a client who is manipulative and disruptive but not demonstrating behaviors that are a threat to self or others, it is essential for the nurse to set clear and consistent boundaries for behavior. This helps establish a therapeutic environment and maintains the safety and well-being of both the client and others in the milieu.

Allowing the client to refuse medications is an important aspect of respecting their autonomy and right to make decisions about their own care, as long as they are not posing a risk to themselves or others. It is important to communicate with the client about the potential consequences of refusing medications and provide information about the benefits of taking prescribed medications to support their mental health.

The other options are not appropriate for the following reasons:

A- Informing the client that a family member will be called to help: Involving family members can be helpful in some situations, but it should not be used as a way to manipulate the client into compliance with treatment. Calling a family member without the client's consent may also violate the client's privacy and autonomy.

B- Preparing discharge paperwork since the client is refusing assistance: Discharging the client solely because they are refusing medication may not be appropriate or ethical if they are not posing a threat to themselves or others. Discharging the client without addressing the underlying issues may not be in the client's best interest and may not resolve the disruptive behavior.

D- Informing the client that without medications, their mental status will not improve: While it is important to provide the client with information about the benefits of medication, using this information as a threat or coercion tactic may not be therapeutic or effective. The nurse should focus on building a trusting relationship with the client and supporting them in making informed decisions about their care.

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Correct Answer is B

Explanation

Explanation: When completing a family assessment for a victim of intimate partner violence, the nurse may identify characteristics of the abuser that contribute to the abusive behavior. Among the options provided, "Needy and possessive of the partner" is the characteristic of the abuser. Abusers often display controlling behavior, which includes possessiveness and excessive need for control over their partners. This possessiveness may manifest as jealousy, isolation, and an attempt to limit the victim's freedom and independence.

A. An ability to feel remorse for the abuse - This characteristic is less likely to be present in an abuser. Abusers often exhibit a lack of remorse for their abusive behavior and may blame the victim or external factors for their actions.

C. An inflated sense of self-esteem - While some abusers may exhibit arrogance and an inflated sense of self-importance, it is not a defining characteristic of all abusers.

D. Encourages the partner to have a life outside the intimate relationship - Abusers typically do the opposite; they often seek to isolate their victims from their support systems and limit their social interactions outside the abusive relationship.

A. Recovery B. Crisis C. Escalation D. Triggering

Correct Answer is C

Explanation

The client's observed behavior of pacing the hall with clenched fists and swearing at others indicates that they are in the escalation phase of the aggression cycle. During this phase, the individual's anger and agitation increase, and their behavior becomes more intense and aggressive. If not addressed promptly and effectively, the situation can escalate further and potentially lead to a crisis or violent outburst.

By intervening immediately and calmly, the nurse aims to prevent the situation from escalating further and moving into the crisis phase, where the risk of harm to the client and others is highest. Effective de-escalation techniques, such as using a calm and non-threatening demeanor, active listening, and providing clear and respectful communication, can help the client regain control and reduce their agitation.

Option A - Recovery: The recovery phase comes after the aggressive incident, during which the individual may feel remorse or embarrassment about their behavior.

Option B - Crisis: The crisis phase is the point where the individual's anger and agitation reach a peak, and there is a high risk of violence or harmful actions.

Option D - Triggering: The triggering phase is the initial phase of the aggression cycle, where the individual's anger begins to build, and certain triggers may set off their aggressive behavior.

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A client is manipulative with staff and disruptive in the milieu. Although the client is not demonstrating behaviors that are a threat to self or others, they are refusing all medications. Which action by the nurse is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is completing a family assessment for a victim of intimate partner violence. Which characteristic of the abuser will the nurse identify when completing the assessment?

Correct Answer is B

Explanation

A client is observed pacing the hall with clenched fists and swearing at others. The nurse intervenes immediately in a calm manner to prevent the client from moving to which phase of the aggression cycle?

Correct Answer is C

Explanation

The nurse is caring for several clients on the behavioral health unit. Which client will be assessed as demonstrating aggression?

An alert, oriented older adult client has been financially and emotionally abused by their adult children for the past several years but has not reported the abuse to anyone. Which reason does the nurse identify is most likely why the client has not reported the abuse?

A client is manipulative with staff and disruptive in the milieu. Although the client is not demonstrating behaviors that are a threat to self or others, they are refusing all medications. Which action by the nurse is most appropriate?

A nurse observes another nurse acting flirtatiously and bringing small gifts, such as candy, to a client in the behavioral health unit. Which action is a priority by the observing nurse?

A nurse is questioning another nurse about whether it is ethical to seclude a client because of loud and intrusive behavior on the unit. Which is the ethical principle that will best guide the nurse's decision on the appropriate use of seclusion?

A client is informed by the nurse that they must take their medication, and the client kicks the nurse and runs to their room. Which action by the nurse demonstrates that the nurse falsely imprisons the client?

An angry client has just thrown a chair across the room and is racing to pick up another chair to throw. Which is the most appropriate action by the nurse?

A nurse is assessing several clients who have experienced loss. Which client will the nurse identify as experiencing complicated grieving? Select all that apply. (Select All that Apply.)