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 C

Explanation

A) Scheduling the client for group therapy with other bulimic clients can be beneficial for support and shared experiences. However, it is not the highest priority intervention at the time of admission, especially if there are immediate health concerns that need to be addressed.

B) Assigning the client's care to a nurse of approximately the same age may help with rapport and understanding, but it does not directly address the critical health risks associated with bulimia nervosa. The age of the nurse is less relevant compared to the immediate medical needs of the client.

C) Assessing and reporting the client's electrolyte status to the healthcare provider is the highest priority. Clients with bulimia nervosa often experience significant electrolyte imbalances due to behaviors such as vomiting, laxative use, or excessive exercise, which can lead to serious complications such as cardiac arrhythmias. Monitoring electrolyte levels is essential for ensuring the client’s safety and guiding further treatment.

D) Monitoring the client carefully for binging activities is an important part of care, but it is secondary to addressing any immediate medical concerns. While observation is necessary to prevent harm, it should occur alongside medical assessments, particularly for electrolyte status, to ensure comprehensive care.

A. Allow the client time alone to sort out any feelings. B. Avoid discussing subjects that upset the client. C. Encourage activities that allow the client to exert control over the client's environment. D. Encourage the client to interact with persons who are recovering from depression.

Correct Answer is C

Explanation

A) Allowing the client time alone to sort out feelings may seem supportive, but isolation can be detrimental, especially for someone who has recently attempted suicide. Social withdrawal can exacerbate feelings of despair and hopelessness. Instead, encouraging engagement with others and structured activities is often more beneficial.

B) Avoiding discussions about subjects that upset the client can lead to avoidance coping and prevent the client from processing important emotions. While it’s important to be sensitive to triggers, avoiding difficult topics may hinder therapeutic progress. Open dialogue is essential for healing and understanding.

C) Encouraging activities that allow the client to exert control over their environment is an effective intervention. This approach helps rebuild a sense of agency and empowerment, which is crucial for clients who may feel helpless after experiencing significant losses. Engaging in structured activities can foster a sense of accomplishment and stability, which can be particularly beneficial for someone recovering from a suicide attempt.

D) Encouraging the client to interact with persons who are recovering from depression can provide valuable support and understanding; however, this may not be the most immediate intervention. The client may still be in a fragile state, and facilitating control through structured activities might be a more effective way to build confidence and a sense of community before introducing peer interactions.

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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 young adult client is admitted to a psychiatric facility with a diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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