A nurse is assessing a newly admitted client in the emergency department who is visibly agitated, pacing, clenching their fists, and shouting, "Everyone here is trying to hurt me!" The nurse needs to de-escalate the situation safely. Which of the following approaches is most appropriate at this time?
"I need you to sit down, relax, and try and talk to me
"Can you help me understand what's making you feel unsafe right now?
"How long have you been feeling like people want to harm you?
"What do you think the staff is doing that makes you feel this way?"
The Correct Answer is B
Rationale:
A. While the intent is to calm the client, commanding the client to "sit down and relax" may escalate agitation, especially when they feel threatened or mistrustful.
B. This response is calm, nonthreatening, and nonjudgmental, and it acknowledges the client’s fear while inviting collaboration, which helps in de-escalating aggression.
C. Asking for a history of the paranoid feelings is not appropriate in the moment of crisis and may increase frustration or confusion.
D. This question could be interpreted as challenging or sarcastic, potentially escalating paranoia and agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. This response is empathetic, supportive, and therapeutic. It validates the nurse’s concern for safety while inviting the client to explore the emotional triggers behind the self-injury, which is key in caring for individuals with BPD.
B. This response is judgmental and dismissive, which can damage the therapeutic relationship and escalate emotional distress in a client with BPD.
C. While medication review may be necessary later, immediately shifting focus to medication ignores the root emotional cause of the behavior and does not address the current crisis therapeutically.
D. Although setting limits is important, this response is overly directive and lacks empathy, which may come off as punitive rather than supportive.
Correct Answer is A
Explanation
Rationale:
A. The superego represents internalized moral standards and ideals from parents and society. When overly dominant, it can lead to excessive guilt, perfectionism, and harsh self-criticism—exactly as described in the client.
B. This describes the ego, which balances the id, superego, and reality—not the superego itself.
C. Repression is a defense mechanism used by the ego to manage anxiety, not a primary function of the superego.
D. This describes the id, which is driven by the pleasure principle—not the superego.
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