A nurse in a mental health facility is caring for a client who is being aggressive toward other clients.
Which of the following actions is the priority for the nurse to take?
Role model healthy ways to express anger.
Assist the client to explore techniques to reduce stress.
Suggest the client make a list of things that make him angry.
Ask the client if he intends to harm others.
The Correct Answer is D
Choice A rationale:
While role modeling healthy ways to express anger is important, it is not the priority when a client is being aggressive toward others. Safety is the primary concern.
Choice B rationale:
Assisting the client to explore techniques to reduce stress is a helpful intervention but is not the priority when the client is actively being aggressive toward others.
Choice C rationale:
Suggesting the client make a list of things that make him angry is a therapeutic intervention, but it is not the priority when the client's behavior poses an immediate threat to others.
Choice D rationale:
Asking the client if he intends to harm others is the priority because it assesses the immediate risk to the safety of others. This information is crucial for determining the appropriate interventions to ensure the safety of everyone in the facility. Depending on the client's response, the nurse can take further steps to manage the aggressive behavior. Safety is the top priority in such situations. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A client with a history of dependent personality disorder does not necessarily require close placement to the nurse's station for safety reasons. The primary concern in this case is not related to Alzheimer's or potential wandering, so placing this client closer to the nurse's station is not warranted.
Choice B Reason: A client who has moderate-stage Alzheimer’s disease.This client should be placed closest to the nurse’s station because individuals with moderate-stage Alzheimer’s disease may experience confusion, memory loss, and wandering, which can lead to safety concerns. Close proximity to the nurse’s station allows for better supervision and prompt intervention.
Choice C rationale:
A client with schizotypal personality disorder may have unique care needs, but these typically do not require placement close to the nurse's station. The primary concern in this case is not related to the safety or wandering associated with Alzheimer's disease.
Choice D rationale:
A client with a history of alcohol use disorder may require monitoring and support but does not necessarily need to be placed close to the nurse's station solely based on this history. The primary concern is not related to Alzheimer's disease or safety due to wandering. In a healthcare setting, clients with Alzheimer's disease often experience confusion and may wander, creating a risk of harm to themselves. Placing a client with moderate-stage Alzheimer's disease close to the nurse's station allows for better supervision and prompt response to any safety concerns. Therefore, it is the most appropriate choice for close placement. .
Correct Answer is A
Explanation
Choice A rationale:
The nurse should ask the client, "How have you dealt with similar situations in the past?" This question is essential to assess the client's personal coping skills. By inquiring about the client's previous experiences in handling similar situations, the nurse can gain insight into the client's coping mechanisms and identify potential strengths and weaknesses. Understanding how the client has coped in the past can help tailor interventions and support to their specific needs.
Choice B rationale:
While asking, "Can you describe how you are currently feeling?" is a valuable question, it primarily focuses on the client's current emotional state and may not provide a comprehensive assessment of their coping skills. It is crucial to understand the client's emotions, but it does not directly address their coping strategies.
Choice C rationale:
"Do you see your current situation affecting your future?" is a forward-looking question that explores the client's perception of how their current situation might impact their future. While this question is relevant, it does not directly assess the client's coping skills and strategies. It focuses more on the client's expectations and outlook.
Choice D rationale:
"How does this situation affect your life?" is a broad question that can provide insights into the client's life and the impact of their current situation. However, it does not specifically address the client's coping skills and strategies. It may provide information about the consequences of their situation but not their ability to cope.
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