A female client admitted to the mental health unit starts to shout and scream at the nurse. Which is the best approach for the nurse to take?

Stay quietly with the client.

Tell her that she is out of control.

Ignore the client's acting out, behavior.

Distract her by offering finger foods.

Answer and Explanation

The Correct Answer is A

A) Staying quietly with the client is the best approach in this situation. By remaining present and calm, the nurse can provide a sense of safety and support. This non-confrontational presence may help the client feel more secure and reduce her agitation over time.

B) Telling the client that she is out of control may escalate her frustration and feelings of being judged. This could worsen the situation rather than help it, as it does not offer any constructive feedback or support.

C) Ignoring the client's acting out behavior is not appropriate. Acknowledging her feelings and providing support is essential, even if her behavior is challenging. Ignoring her could lead to further escalation and feelings of isolation.

D) Distracting her by offering finger foods could be an effective strategy if the client is calm enough to engage in that activity. However, if she is currently shouting and screaming, she may not be receptive to distraction techniques. Addressing her emotional state first is more critical.

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Correct Answer is A

Explanation

A) Recalling methods that were most successful in the past is an effective coping strategy. This approach encourages the client to identify and utilize strategies that have previously helped them manage their depression. It fosters a sense of agency and can inspire motivation to engage in positive behaviors again.

B) Turning to other activities to take one's mind off of the issues may provide temporary relief, but it does not address the underlying issues related to depression. This strategy could lead to avoidance rather than active problem-solving and engagement with life.

C) Reaching out to family and friends about feelings of abandonment is important for social support; however, it may not be the first step in the coping strategy. The client may need to develop skills to articulate their feelings before reaching out, and it also doesn’t directly address their current disengagement from activities.

D) Relaxing and reducing the amount of effort to solve the problem may feel appealing but could reinforce avoidance behaviors. It’s crucial to encourage the client to engage actively with their emotions and challenges instead of stepping back entirely. The goal should be to empower the client to take small, manageable steps toward re-engagement with life, making option A the most suitable choice.

A. Disrupts group activities. B. Talks with nonsensical words. C. Refuses antipsychotic medications. D. Wanders into client's rooms.

Correct Answer is D

Explanation

A) Disrupting group activities indicates behavioral issues, but it alone does not necessarily warrant constant observation. While disruptive behavior can be concerning, it may not pose an immediate risk to the client or others.

B) Talking with nonsensical words suggests disorganized thinking or possible psychosis, which is important to note. However, this behavior does not by itself indicate that the client is in immediate danger or that they require constant observation.

C) Refusing antipsychotic medications is a significant factor, particularly in managing the client's mental health. However, refusal of medication does not automatically necessitate constant observation unless it leads to behaviors that put the client or others at risk.

D) Wandering into clients' rooms is the most concerning behavior in this context. This action can pose a risk to both the individual and other clients, potentially leading to boundary violations or safety issues. Constant observation is warranted to ensure the safety of all clients and to manage the individual's behavior effectively.

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A female client admitted to the mental health unit starts to shout and scream at the nurse. Which is the best approach for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with depression is not attentive to personal hygiene, uses television watching as a means of escape from responsibilities, and describes an inability to enjoy the things that once gave them pleasure. Which coping strategy should the nurse include in the plan of care?

Correct Answer is A

Explanation

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client's rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

Correct Answer is D

Explanation

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