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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A Reason:
This statement is an example of assertive communication because it acknowledges the client's feelings while also standing firm on the nurse's actions. Assertive communication is characterized by being direct, clear, concise, honest, confident, and respectful¹. It involves expressing thoughts and feelings in a considerate way that respects others, aiming to foster and maintain healthy relationships, rectify conflicts, and prevent resentment due to unexpressed needs.

Choice B Reason:
Telling a client to calm down can be perceived as dismissive and may not be considered assertive communication. It does not acknowledge the client's feelings and can come across as commanding or condescending, which may escalate the situation rather than resolve it.

Choice C Reason:
While this statement does convey the consequences of the client's actions, it lacks the empathy component that is crucial in assertive communication. It is important to balance directness with understanding when addressing sensitive issues.

Choice D Reason:
Asking why the client chose to behave negatively could be seen as confrontational and may put the client on the defensive. Assertive communication aims to avoid power games and foster clear outcomes, which is best achieved through statements that do not provoke or blame.

A. Directly tell the client that the delusions are not real. B. Use frequent touch to provide client support. C. Place the client in seclusion if visual hallucinations are present. D. Limit the number of questions asked during assessments.

Correct Answer is D

Explanation

Choice A Reason:
Directly telling a client that their delusions are not real is not typically recommended. This approach can be confrontational and may lead to increased anxiety or agitation in the client. It's important to maintain a therapeutic relationship by validating the client's feelings and working within their current reality, rather than directly challenging their perceptions.

Choice B Reason:
Using frequent touch to provide support may not be appropriate for all clients, especially those with schizophrenia who may have altered perceptions of reality. Some individuals may find touch comforting, while others may perceive it as threatening or invasive. It's crucial to assess each client's comfort level with physical contact and proceed accordingly.

Choice C Reason:
Placing a client in seclusion can be a traumatic experience and is generally considered a last resort when other interventions have failed and the client is a danger to themselves or others. Seclusion should not be used solely because a client is experiencing visual hallucinations.

Choice D Reason:
Limiting the number of questions during assessments can help reduce the potential for overwhelming the client. Clients with schizophrenia may have difficulty processing too much information at once, and a barrage of questions can be stressful. Simplifying communication and allowing the client to focus on one question at a time can be more effective.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health facility is caring for a client who is upset about the loss of privileges due to repetitive negative behavior. Which of the following statements by the nurse demonstrates the effective use of assertive communication?

Correct Answer is A

Explanation

A nurse is developing a care plan for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should the nurse take?

A nurse is discussing therapeutic milieu with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of therapeutic milieu?

A nurse is caring for a client diagnosed with severe manifestations of schizophrenia and is prescribed haloperidol (Haldol) PRN for agitation. The nurse should recognize which of the following as adverse effects of haloperidol (Haldol)?

A nurse working in a mental health facility is utilizing milieu therapy to provide a therapeutic environment for their clients. Which of the following steps of the nursing process is the nurse demonstrating?

A nurse is teaching about physiological responses to stress with a group of clients. The nurse should identify that which of the following changes reflect long-term physiological responses to stress? (Select all that apply)

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