A nurse in a mental health facility is planning a training program for new staff members on managing aggressive clients. Which of the following instructions should the nurse plan to include?
Assume authority by standing directly in front of the client.
Attempt to calm the client with therapeutic touch.
Offer the client a PRN medication to reduce their anxiety.
Bring other staff members to talk the client down.
The Correct Answer is C
Choice A reason: Standing directly in front of an aggressive client may be perceived as threatening and escalate the situation. Staff should maintain a safe distance and non-confrontational posture.
Choice B reason: Therapeutic touch is contraindicated in aggressive situations. Physical contact may provoke further aggression or be misinterpreted.
Choice C reason: Offering PRN medication is a safe and effective de-escalation strategy. It helps reduce agitation and prevent escalation when used appropriately.
Choice D reason: Bringing multiple staff members may overwhelm or intimidate the client. It should only be done if safety is compromised and intervention is necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: While understanding family dynamics is important for long-term management, it does not address immediate safety concerns. It is more relevant during psychosocial assessments or discharge planning.
Choice B reason: Assessing for suicidal ideation is a priority in clients with bipolar disorder due to the high risk of self-harm during depressive or mixed episodes. This question directly addresses safety and guides urgent intervention if needed.
Choice C reason: This question may assess judgment or abstract thinking but is not a priority in acute assessment. It is more appropriate in cognitive or neuropsychological evaluations.
Choice D reason: Asking about favorite color is irrelevant to psychiatric assessment and does not provide useful clinical information.
Correct Answer is A
Explanation
Choice A reason: Failure to administer prescribed medication is a medication error and must be documented through an incident report. This ensures accountability, promotes safety, and initiates corrective action to prevent recurrence.
Choice B reason: Aggressive behavior may be part of the client’s psychiatric presentation. Unless it results in harm or requires emergency intervention, it may not meet the threshold for an incident report unless facility policy dictates otherwise.
Choice C reason: Missing a therapy session is not typically considered an incident unless it results in harm or is part of a pattern requiring intervention. It should be documented in progress notes, not an incident report.
Choice D reason: Refusal to leave the room may indicate worsening depression but does not constitute an incident unless it leads to harm or safety concerns. It should be addressed in the care plan.
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