A nurse is caring for multiple clients on a mental health unit.
Which of the following clients should the nurse attend to first?
A client who is repeatedly approaching the nurses' station to request medication for his anxiety.
A client who is standing in her room, yelling obscenities, and throwing her clothes.
A client who has bipolar disorder and is continuously pacing at the end of the hall.
A client in the dayroom who is screaming at other clients about what is on the television.
The Correct Answer is B
Choice A rationale
While this client may need attention, the behavior is not immediately dangerous.
Choice B rationale
This client requires immediate attention due to the risk of harm to herself and others through throwing objects and yelling, which indicates potential for escalation.
Choice C rationale
Pacing, although concerning, does not pose an immediate risk of physical harm compared to Choice B.
Choice D rationale
The client is disruptive but not immediately dangerous compared to the client in Choice B who poses a more direct risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Relaxation exercises can help manage anxiety but are not the immediate first action required for a newly admitted client.
Choice B rationale
Explaining response prevention is useful for OCD treatment but isn't the first priority upon admission.
Choice C rationale
Administering medication can alleviate anxiety symptoms but isn't the first action that establishes a comprehensive assessment.
Choice D rationale
Calculating the Hamilton Rating Scale for Anxiety provides an initial assessment of the client's anxiety severity, guiding further interventions.
Correct Answer is D
Explanation
Choice A rationale
Role-playing is a therapeutic technique that helps children practice and learn new behavioral skills. However, it is not the primary focus of the redirection technique.
Choice B rationale
Moving closer to an agitated child can sometimes be perceived as threatening or intimidating, which could escalate the situation. Redirection aims to calm and distract the child.
Choice C rationale
Ignoring attention-seeking behaviors can be effective in reducing these behaviors over time, but it is not part of the redirection technique.
Choice D rationale
Re-engaging the child in an appropriate activity is a key part of the redirection technique. It helps divert the child's attention away from the undesired behavior and encourages positive behavior.
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