A nurse in an acute care mental health facility is sitting with a group of clients in a meeting room. A client suddenly jumps up and begins yelling angrily. Which of the following actions should the nurse take to ensure environmental safety?

Give the client more than one choice for resolving the conflict.

Move toward the client using an aggressive stance.

Choose two staff members to represent the staff and speak to the client.

Stand between the client and the doorway of the room.

Answer and Explanation

The Correct Answer is D

A. Give the client more than one choice for resolving the conflict. While providing choices can be beneficial in some situations, it is not a direct action to ensure immediate environmental safety when a client is escalating aggressively.
B. Move toward the client using an aggressive stance. This approach is inappropriate and can escalate the situation further. A calm and non-threatening demeanor is essential in managing an aggressive client.
C. Choose two staff members to represent the staff and speak to the client. Having multiple staff members engage with an agitated client can sometimes help, but it’s crucial that any interaction is done calmly and without escalating the situation.
D. Stand between the client and the doorway of the room. This is the most appropriate action to ensure safety. Positioning yourself between the client and the exit can prevent the client from leaving the room and potentially harming themselves or others while ensuring a safe space to de-escalate.

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Correct Answer is C

Explanation

A. "My mother had a heart attack at 60 years old." Family history of cardiovascular disease is a risk factor, but this statement alone doesn’t provide a full picture of the client’s risk without other factors.
B. "I will be 50 years old on my birthday this year." Age is a risk factor for cardiovascular disease, but being 50 alone does not necessarily indicate an elevated risk without considering other factors like lifestyle and health status.
C. "My latest cholesterol level was 190." A cholesterol level of 190 mg/dL is borderline high and can be a risk factor for cardiovascular disease. This statement is indicative of a potential risk factor.
D. "I have a BMI of 28." A BMI of 28 indicates overweight, which is a risk factor for cardiovascular disease. This is a relevant indicator of risk but is not the only factor to consider.

A. African Americans B. Southeast Asians C. Northern European Caucasians D. Alaskan natives

Correct Answer is A

Explanation

A. African Americans Sickle cell disease is most prevalent among African Americans and people of African descent.
B. Southeast Asians This group is more at risk for thalassemia, not sickle cell disease.
C. Northern European Caucasians This group is more at risk for cystic fibrosis, not sickle cell disease.
D. Alaskan natives This group is not at a higher risk for sickle cell disease.

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A nurse in an acute care mental health facility is sitting with a group of clients in a meeting room. A client suddenly jumps up and begins yelling angrily. Which of the following actions should the nurse take to ensure environmental safety?

Nursing Test Bank

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