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 B

Explanation

A) While understanding the reason for the suicide attempt can provide important context, it is not as critical in the immediate management of a suspected overdose as knowing the specifics of what was ingested.

B) Identifying the drug that was ingested is the most important information for the nurse to obtain. Knowing the specific substance allows for appropriate and timely treatment, including the administration of antidotes if applicable and understanding potential complications.

C) The time since drug ingestion is also relevant, as it can influence treatment decisions and urgency. However, without knowing the specific drug, it may be challenging to determine the best course of action.

D) A past history of depression is important for the overall understanding of the client's mental health, but it does not have immediate implications for managing an overdose. The priority is to address the acute medical situation first.

A. Offer a referral to pastoral counseling. B. Suggest the need for a psychiatric consultation. C. Explore changes in life that have occurred after the loss. D. Encourage attending a local support group.

Correct Answer is C

Explanation

A) Offering a referral to pastoral counseling can be helpful, but it may not address the immediate emotional needs of the client who is experiencing extreme sadness and difficulty controlling emotions. This option can be considered later in the therapeutic process.

B) Suggesting the need for a psychiatric consultation might be appropriate, but it could be premature at this point. The focus should first be on understanding the client’s current emotional state and helping them process their grief.

C) Exploring changes in life that have occurred after the loss is the first and most important action. This approach allows the nurse to facilitate the client’s expression of feelings, which is crucial in the grieving process. By discussing the impact of the loss, the nurse can provide emotional support and help the client begin to process their grief.

D) Encouraging attendance at a local support group can be beneficial, but it may not be the most immediate action. The client needs to be heard and understood in their current emotional state before considering additional resources or support systems.

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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

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Explanation

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