A nurse is assisting in the admission process for a client who has a history of violent behavior. The client stands up and begins clenching her fists and arguing with the nurse. Which of the following actions is the priority?

Explore the truth of the client's statements.

Establish a therapeutic nurse-client relationship.

Set behavioral limits for the client

Show the client around the unit and introduce her to other clients.

Answer and Explanation

The Correct Answer is C

The priority action in this situation is to set behavioral limits for the client. This is important for maintaining a safe environment for the client, other staff members, and other clients. By setting limits, the nurse establishes clear boundaries and expectations for behavior, helping to prevent the escalation of aggression or violence.
Let's examine why the other choices are incorrect:

A. Exploring the truth of the client's statements: While it is important to listen to and validate the client's concerns, in this particular situation, where the client is becoming agitated and confrontational, addressing the truth of their statements is not the priority. The immediate concern is ensuring safety and de-escalating the situation.

B. Establishing a therapeutic nurse-client relationship: Developing a therapeutic relationship is crucial for providing effective care, but it may not be the immediate priority when a client is displaying aggressive or violent behavior. Safety takes precedence in such situations, and setting behavioral limits is necessary before establishing a therapeutic relationship can effectively occur.

D. Showing the client around the unit and introducing her to other clients: This action is inappropriate during an agitated and confrontational episode. It is important to first
address the client's behavior and ensure the safety of all individuals involved before engaging in social activities or introductions.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Validation is a technique used to acknowledge and validate the emotions and experiences of individuals with dementia, even if their thoughts or perceptions do not align with reality. In this scenario, the nurse responds by saying, "You miss your mother," which shows understanding and empathy toward the client's emotions. The nurse is validating the client's feelings rather than attempting to correct or redirect their thoughts.

A. Orientation to reality involves providing factual information and attempting to reorient individuals with dementia to the present time, place, and situation.

B. Remotivation is a technique used to stimulate memories and engage individuals with dementia in meaningful activities.

D. Guided imagery involves using vivid language and descriptive prompts to guide individuals into imagining pleasant or calming scenes.

A. "You really should work hard to stay on the schedule we establish here." B. "I wouldn't worry about what you've done in the past. You'll do just fine this time." C. "Why do you find it difficult to take your medications if they improve your condition?" D. "Let's work together to devise a schedule that is convenient for you on a daily basis."

Correct Answer is D

Explanation

The response "Let's work together to devise a schedule that is convenient for you on a daily basis" demonstrates a collaborative and patient-centered approach. It acknowledges the client's difficulty in following a medication regimen and suggests finding a solution that works for the client's lifestyle and needs. By involving the client in the process and considering their preferences and challenges, the nurse can increase the chances of medication adherence.

The response "You really should work hard to stay on the schedule we establish here" may come across as judgmental and may not address the underlying reasons for the client's difficulty in medication adherence. It does not promote a collaborative and supportive environment.

The response "I wouldn't worry about what you've done in the past. You'll do just fine this time" dismisses the client's concerns and does not provide practical strategies to improve medication adherence. It does not address the client's specific challenge or offer any support.

The response "Why do you find it difficult to take your medications if they improve your condition?" is a probing question that seeks to understand the client's reasons for struggling with medication adherence. While it may be important to explore the underlying reasons, it should be followed by a supportive and collaborative approach to finding solutions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assisting in the admission process for a client who has a history of violent behavior. The client stands up and begins clenching her fists and arguing with the nurse. Which of the following actions is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who has dementia and is agitated. The client says, "I have to go home and see my mother." The nurse replies, "You miss your mother." Which of the following therapeutic techniques is the nurse using?

Correct Answer is C

Explanation

A nurse is reinforcing discharge teaching with a client who has several new prescriptions for psychotropic medications. The client tells the nurse that she has always had trouble following a medication regimen. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse observes that a client is sitting alone in her room crying. As the nurse approaches, she states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses is appropriate for the nurse?

A nurse is caring for a client with whom he has developed a therapeutic relationship and who will be discharged later in the day. The client thanks the nurse for his help during the hospitalization. Which of the following responses should the nurse make?

A nurse is collecting data from a client whose child was killed 2 years ago. Which of the following actions Indicates that the client is experiencing maladaptive grieving?

A nurse is reinforcing teaching with a client who is scheduled to receive electroconvulsive therapy (ECT). Which of the following statements should the nurse include in the teaching?

A nurse in a long-term care facility is caring for an older adult client who is anxious and has trouble sleeping at night. Which of the following nursing measures should the nurse implement?

A nurse is planning an Interview for a newly admitted client and plans to Include the client's family members. Which of the following methods should the nurse use to determine who to include in the interview?