A novice nurse is beginning work on a behavioral health unit and states to the preceptor, "What if I encounter a client that is sexually aggressive? Which is the appropriate response by the preceptor?
"Set firm limits and boundaries for the client."
“Tell the client that you are going to report to the director of the unit.”
"Walk away and have someone else take care of the client."
"It happens frequently so just ignore it they will stop."
The Correct Answer is A
When encountering a client who is sexually aggressive, it is important for the nurse to establish firm limits and boundaries to ensure the safety and well-being of both the client and the healthcare team. This response promotes the maintenance of a therapeutic environment and helps prevent potential harm to the client, staff, and other patients.
the other choices are incorrect:
1. "Tell the client that you are going to report to the director of the unit." While it is important to report any concerning behaviors or incidents to the appropriate personnel, simply informing the client about reporting to the director may not be the most effective initial response. Prioritizing immediate actions to ensure safety and setting boundaries is crucial before involving higher-level staff.
2. "Walk away and have someone else take care of the client." Leaving the situation and passing the responsibility to someone else without addressing the issue directly is not an appropriate response. It is the nurse's responsibility to provide care and manage challenging situations within their scope of practice and training. Collaboration and support from the healthcare team may be sought, but abandoning the client is not an acceptable approach.
3. "It happens frequently, so just ignore it; they will stop." Ignoring sexually aggressive behavior is not an appropriate response. Such behavior should be taken seriously and addressed promptly to ensure the safety and well-being of everyone involved. Ignoring the behavior may enable its continuation and potentially lead to further harm or escalation of the situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["4.54"]
Explanation
To convert pounds (lbs) to kilograms (kg), we need to use the conversion factor: 1 pound = 0.45359237 kilograms
Now, let's calculate the weight of the baby in kilograms:
Weight in kilograms = Weight in pounds * Conversion factor
Weight in kilograms = 10 lbs * 0.45359237 kg/lb
Weight in kilograms ≈ 4.5359237 kg
Therefore, the baby weighs approximately 4.54 kilograms.
Correct Answer is C
Explanation
When creating a plan of care for a client experiencing a situational crisis, it is important to set measurable and obtainable goals that can guide the client's progress and provide clear indicators of achievement.
Considering the options provided, the most measurable and obtainable goal for the client experiencing a situational crisis would be:
The client will resume the pre-crisis level of functioning.
This goal is measurable as it involves assessing the client's functioning before the crisis and monitoring their progress in returning to that level. It is also obtainable as it focuses on restoring the client's previous abilities and skills, rather than relying on subjective or introspective factors. By setting specific criteria to determine the pre-crisis level of functioning and regularly evaluating the client's progress, the nurse can measure the client's achievement of this goal and adjust the plan of care accordingly.
The client will resume the pre-crisis level of functioning: Resuming the pre-crisis level of functioning is a measurable and obtainable goal. It involves identifying the client's previous level of functioning and working towards returning to that state. By assessing the client's functional abilities before the crisis and monitoring progress over time, it is possible to measure and track the extent to which they have regained their previous level of functioning.
The client will discover a new sense of self-sufficiency in coping: While this goal is important for the client's long-term growth and development, it is not easily measurable or obtainable in a specific timeframe. "Discovering a new sense of self-sufficiency" is a subjective and introspective process that may require extensive self-reflection and personal growth, making it difficult to measure and set a concrete timeline for achievement.
The client will express anger regarding the crisis event: Expressing anger can be a normal and healthy part of the healing process during a crisis. However, it is not necessarily the most
measurable or obtainable goal. The expression of anger can vary greatly among individuals, and it may not be an appropriate or necessary response for everyone. Additionally, the focus of the plan of care should extend beyond anger expression and encompass a broader range of emotions and coping strategies.
The client will identify possible causes for the crisis: While understanding the possible causes of the crisis can be an important part of the recovery process, it may not be the most measurable or obtainable goal on its own. Identifying the causes of a crisis can involve complex factors that may require professional assessment and a deeper exploration of the client's history and circumstances. It is more appropriate as an ongoing process within therapy rather than a specific goal with a clear endpoint.
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