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.

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Correct Answer is C

Explanation

Repression is a defense mechanism that involves pushing distressing or anxiety-provoking thoughts, memories, or impulses into the unconscious mind. By repressing these thoughts, the individual can avoid dealing with the associated anxiety or discomfort. In the given scenario, the client escapes from anxiety-causing thoughts by ignoring their existence, which aligns with the concept of repression.

Denial, another defense mechanism, involves refusing to acknowledge the existence of a distressing reality or truth. However, in this case, the client is not denying the existence of the thoughts but rather ignoring or avoiding them.

Splitting is a defense mechanism characterized by the inability to integrate positive and negative qualities of oneself or others into a cohesive whole. It is not applicable in this situation.

Sublimation is a defense mechanism in which individuals redirect their unacceptable impulses into more socially acceptable outlets. It involves channeling potentially harmful or unacceptable desires into constructive behaviors. The given scenario does not reflect sublimation as the individual is not redirecting their anxiety into a productive activity or behavior.

A. "Don't worry. We'll take good care of your father while you are gone." B. "Perhaps you could stay here and just call your family to see how they are doing." C. "There's nothing you can do here. You should go home to your family." D. "You are feeling drawn in two different directions."

Correct Answer is D

Explanation

The response "You are feeling drawn in two different directions" acknowledges the daughter's conflicting feelings and validates her emotions. It demonstrates empathy and understanding of her situation. It can help the daughter feel heard and supported and opens up an opportunity for further conversation about her concerns and possible solutions.

The other options are less appropriate:

A- "Don't worry. We'll take good care of your father while you are gone." While this response reassures the daughter about her father's care, it does not address her emotional conflict or provide support for her own needs and concerns.

B- "Perhaps you could stay here and just call your family to see how they are doing." This response minimizes the daughter's situation and does not fully acknowledge her need to be with her own family. It may overlook the emotional strain and responsibilities she may have outside of the hospital.

C-"There's nothing you can do here. You should go home to your family." This response dismisses the daughter's feelings and implies that her presence is not necessary or valuable. It does not consider her desire to support her father or the importance of maintaining a connection with him during his hospitalization.

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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 a client who escapes anxiety-causing thoughts by ignoring their existence. The nurse should recognize this behavior as which of the following defense mechanisms?

Correct Answer is C

Explanation

A nurse is caring for an older adult client admitted to the hospital following a cerebrovascular accident. The client's daughter tells the nurse, "I wish I could stay with my father, but I need to go home to my family." Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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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?