A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply)

Speak to the client in a loud voice

Stand directly in front of the client

Request that security guards restrain the client

Talk to the client using short, simple sentences

Identify the client’s stressors

Answer and Explanation

The Correct Answer is D

Choice A reason: Speaking loudly escalates tension in an agitated client, mimicking confrontation and potentially worsening yelling or pacing. De-escalation requires a calm, low tone to soothe, not provoke. This action contradicts mental health principles for managing agitation, increasing risk, so it’s not appropriate here.

Choice B reason: Standing directly in front risks invading personal space, heightening agitation in a yelling, pacing client, possibly triggering aggression. A side approach maintains safety and openness, per de-escalation guidelines. This position endangers the nurse and client, making it an incorrect choice.

Choice C reason: Requesting restraints assumes immediate danger without de-escalation attempts, violating least restrictive care. Yelling and pacing alone don’t justify physical control unless harm is imminent. This premature escalation skips verbal intervention, so it’s not suitable unless safety fails.

Choice D reason: Short, simple sentences calm the client by reducing cognitive overload during agitation, facilitating understanding amid yelling and pacing. This de-escalation technique, part of crisis management, promotes cooperation safely. It’s a primary, effective step, making it a correct action here.

Choice E reason: Identifying stressors uncovers agitation triggers (e.g., fear, pain), guiding tailored de-escalation for a yelling, pacing client. This insight informs interventions, reducing escalation risk in mental health settings. It’s a proactive, therapeutic step, correctly included in the nurse’s response.

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Correct Answer is C

Explanation

Choice A reason: Discussing a spiritual counselor addresses potential comfort but assumes spiritual needs without assessment, not an immediate priority. Complicated grieving requires normalizing emotions first to build trust and coping. This intervention is supportive but secondary to addressing current feelings, so it’s not the top focus now.

Choice B reason: Identifying the grief stage (e.g., Kubler-Ross) provides insight but isn’t urgent in complicated grief, where emotions like anger dominate. It’s a tool for understanding, not immediate relief. Normalizing feelings takes precedence to prevent escalation, making this less critical initially.

Choice C reason: Informing the client anger is expected validates their emotions in complicated grief, a priority to reduce isolation and guilt after a child’s death. This normalization prevents worsening distress, aligning with safety and emotional stabilization, the first step in care, making it the correct choice.

Choice D reason: Encouraging physical activity promotes health but doesn’t address acute emotional pain in complicated grief, a secondary coping strategy. Anger and loss need validation before behavioral interventions. This action lacks immediacy for the client’s current state, so it’s not the priority.

A. Convey sympathy for the client’s experience B. Tell the client her experience is not real C. Avoid asking direct questions about the client’s experience D. Focus the client on reality-based activities

Correct Answer is D

Explanation

Choice A reason: Conveying sympathy (pity) risks reinforcing hallucinations as a shared burden, not a symptom to manage, potentially confusing the client. It lacks therapeutic redirection to reality, key in psychosis. This emotional response doesn’t aid coping, so it’s less effective here.

Choice B reason: Telling the client hallucinations aren’t real dismisses their perception, often escalating agitation in psychosis, as they feel invalidated. It ignores the subjective reality of schizophrenia, breaking trust. This confrontational approach contradicts care standards, making it inappropriate.

Choice C reason: Avoiding questions about hallucinations limits insight into their content or triggers, hindering assessment and tailored intervention. Asking directly (e.g., What do you hear?) informs care, so this passive stance reduces effectiveness. It’s not the best action for managing active symptoms.

Choice D reason: Focusing on reality-based activities (e.g., grounding tasks) distracts from hallucinations, reorienting the client to the present, a standard psychosis intervention. It reduces symptom intensity without confrontation, enhancing coping. This aligns with evidence-based practice, making it the correct choice.

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A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has complicated grieving following the death of her child. Which of the following interventions should the nurse identify as the priority?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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