A nurse enters the room of a client who becomes verbally abusive. Which of the following actions should the nurse take?
Remain a distance of 1 ft away from the client.
Speak slowly in a low, calm voice.
Forbid the client from speaking in an abusive manner.
Inform the client of consequences.
The Correct Answer is B
Choice A reason: Standing 1 ft away from a verbally abusive client is too close and may escalate the situation by invading their personal space. Maintaining a safe distance (about 3–6 ft) is recommended for safety.
Choice B reason: Speaking slowly in a low, calm voice helps de-escalate the situation by modeling calm behavior and reducing the client’s agitation. This approach promotes a safe environment and encourages de-escalation.
Choice C reason: Forbidding the client from speaking abusively may escalate their agitation, as it can be perceived as confrontational. A non-confrontational approach, like staying calm, is more effective.
Choice D reason: Informing the client of consequences may be appropriate later, but it is not the first action. De-escalation through calm communication is the priority to manage the immediate verbal abuse safely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:A suicide in a mental health facility is a traumatic event for staff, who may experience guilt, grief, or burnout. Providing professional counseling as the priority intervention supports staff mental health, enabling them to process the event, maintain their well-being, and continue providing safe, effective care to other clients.
Choice B reason:Supporting the family’s emotional needs is important, but it is not the immediate priority. Staff must first address their own psychological well-being to ensure they can provide compassionate and professional support to the family and other clients effectively.
Choice C reason:Reviewing the client’s behavior for missed warning signs is valuable for learning and improving future care. However, this retrospective analysis is not the immediate priority, as it does not address the urgent emotional needs of staff following the traumatic event.
Choice D reason:Updating observation policies could enhance future suicide prevention, but it is not the immediate priority. Policy changes require time and analysis, whereas supporting staff mental health is critical to maintaining unit functionality and safety in the aftermath of the incident.
Correct Answer is A
Explanation
Choice A reason: Disorganized, rapid, or pressured speech is a hallmark symptom of acute mania and reflects flight of ideas.
Choice B reason: Recent weight gain may relate to medication side effects or other conditions, not mania specifically.
Choice C reason: Hearing voices is a hallucination, which suggests psychosis or schizophrenia, not acute mania.
Choice D reason: Wearing all black may indicate a personal preference, not a diagnostic feature of mania.
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