A home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. The client is sitting on his front porch with a shotgun in his arms. Which of the following actions should the nurse take?
Stop the car in the client's driveway and call the authorities.
Honk the car horn to get the client's attention.
Calmly speak the client's name out of the car window.
Keep driving in a path that is going away from the client's house.
The Correct Answer is D
Choice A reason:
Stop the car in the client’s driveway and call the authorities. This statement is wrong because stopping in the driveway could escalate the situation and put the nurse in immediate danger. The nurse should avoid any actions that might provoke the client or put herself in harm’s way.
Choice B reason:
Honk the car horn to get the client’s attention. This statement is wrong because honking the horn could startle the client, potentially leading to a violent reaction. Sudden loud noises can exacerbate agitation in individuals with schizophrenia.
Choice C reason:
Calmly speak the client’s name out of the car window. This statement is wrong because engaging with the client directly while they are armed is unsafe and could provoke aggression. The nurse should avoid direct interaction until the situation is secured.
Choice D reason:
Keep driving in a path that is going away from the client’s house. This is the correct action as it ensures the nurse’s safety by distancing herself from the potentially dangerous situation. Once at a safe distance, the nurse can contact the authorities for assistance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
An unwillingness to accept that treatment is needed is not, by itself, a condition that can legally justify extending a hospital hold beyond the initial 72 hours. Treatment refusal can be a complex issue and may require a deeper understanding of the client's capacity to make informed decisions.
Choice B reason:
The client's intention to move out of the state does not constitute a legal basis for extending a hospital hold. The focus of continued hospitalization would be on immediate safety concerns rather than future living arrangements.
Choice C reason:
Disliking a neighbor is not a condition that warrants an extended hospital hold. Personal feelings or disputes do not equate to a risk that justifies involuntary hospitalization.
Choice D reason:
If the client poses a danger to themselves or others, this is a condition under which the hospital can legally extend the hold beyond 72 hours. The primary concern is the safety of the client and those around them, and if there is a risk of harm, the client may be held involuntarily until it is deemed safe for them to be discharged.
Correct Answer is C
Explanation
Choice A Reason:
Universality refers to the realization among group members that they are not alone in their experiences or feelings. While the interaction does show a shared experience, the primary factor demonstrated here is not just the commonality of experience but the encouragement and hope it provides.
Choice B Reason:
Imitative Behavior involves group members learning from each other by observing and copying behaviors. In this scenario, while the member who has been sober for 7 years may serve as a role model, the key element in this interaction is the hope conveyed through sharing personal success.
Choice C Reason:
Instillation of Hope is the encouragement that recovery is possible. The member's statement about overcoming multiple relapses and achieving long-term sobriety serves as a powerful testament to the possibility of recovery, thus instilling hope in others.
Choice D Reason:
Altruism is the unselfish concern for the welfare of others, which can be a byproduct of group therapy as members support each other. However, the primary factor at play in this scenario is the provision of hope rather than the act of giving support.
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