A nurse is in the day room of an acute care mental health facility with a group of clients who are watching television.

Suddenly, one of the clients jumps up screaming and runs out of the room.

What should the nurse do next?

Ask the group what they think about the client’s behavior.

Stay with the group and ask another client to go and check on the situation.

Follow the client to determine the cause of the behavior.

Ignore the incident since it is an attention-seeking behavior.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Asking the group what they think about the client's behavior is not appropriate for several reasons. It could violate the client's confidentiality, it could create a sense of judgment or stigma among the group members, and it is unlikely to provide accurate or helpful information about the cause of the behavior. The nurse's primary responsibility is to the client who is experiencing distress, not to gather opinions from others.

Choice B rationale:

Staying with the group and asking another client to check on the situation is also not appropriate. It is the nurse's responsibility to assess and address the client's behavior, not to delegate this task to another client. This could potentially put the other client at risk, as they may not have the training or skills to handle the situation effectively. Additionally, it could create a sense of division or lack of support within the group.

Choice D rationale:

Ignoring the incident is never appropriate, as it could potentially endanger the client or others. It is important to remember that all behaviors have meaning, and even attention-seeking behaviors can be a sign of underlying distress. The nurse needs to assess the situation to determine the cause of the behavior and provide appropriate interventions.

Choice C rationale:

Following the client to determine the cause of the behavior is the most appropriate action for the nurse to take. This allows the nurse to assess the client's safety, provide support, and intervene as necessary. It also demonstrates to the client that the nurse is concerned and willing to help. Key considerations for the nurse:

Safety: The nurse's primary concern is always the safety of the client, themselves, and others. It's crucial to assess for any potential risks of harm and take appropriate precautions.

Assessment: Careful observation and assessment of the client's behavior, including verbal and nonverbal cues, can provide valuable insights into the underlying causes.

Communication: Establishing a calm, supportive, and non-judgmental communication with the client is essential to gain their trust and cooperation.

Intervention: The nurse may need to employ various interventions, such as de-escalation techniques, distraction, or medication, depending on the assessment and the client's needs.

Documentation: Thorough documentation of the incident, the nurse's assessment, and interventions is important for continuity of care and communication with other healthcare professionals.

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Correct Answer is A

Explanation

Choice A rationale:

Ideas of reference are a type of delusion in which a person believes that unrelated events, objects, or actions in the environment have personal significance or meaning specifically directed towards them. In this case, the client with schizophrenia misinterpreted the group's laughter as mockery directed specifically at them, even though the story was unrelated to them.

Here's a detailed explanation of why the other choices are incorrect: B. Grandeur:

Grandiosity involves an inflated sense of self-importance, power, or identity. It's not evident in this scenario, as the client isn't expressing beliefs of exceptional abilities or status. C. Somatic delusion:

Somatic delusions focus on bodily functions or sensations, such as believing organs are rotting or insects are crawling under the skin. The client's outburst isn't related to bodily concerns. D. Erotomania:

Erotomania is a delusion where a person believes someone of higher status is in love with them. It's not applicable in this situation as the client's belief isn't about romantic interest.

A. Medication compliance. B. Adverse reactions. C. Medication interactions. D. Dosage adjustments.

Correct Answer is A

Explanation

Choice A rationale:

Medication compliance is crucial in the management of BPD because:

Instability and Impulsivity: Individuals with BPD often struggle with impulsivity and unstable moods, which can lead to inconsistent medication adherence. They may forget to take their medications, take them at the wrong times, or stop taking them altogether when they feel better or worse. This can disrupt the therapeutic effects of the medications and increase the risk of relapse or worsening symptoms.

Multiple Medications: BPD is often treated with a combination of medications, such as mood stabilizers, antidepressants, and antipsychotics. Each medication has its own unique dosing schedule, side effects, and potential for interactions. Monitoring compliance ensures that the client is taking all medications as prescribed, reducing the risk of adverse events and optimizing treatment outcomes.

Mental Health Stigma: Unfortunately, mental health stigma can contribute to medication noncompliance. Individuals with BPD may feel ashamed or embarrassed about their diagnosis, leading them to hide their medication use or avoid taking medications altogether. By openly discussing medication compliance and addressing any concerns, nurses can help reduce stigma and promote adherence.

Therapeutic Relationship: A strong therapeutic relationship between the nurse and client is essential for promoting medication compliance in BPD. Nurses can foster trust and open communication by:

Actively listening to the client's concerns about medications.

Providing clear and concise education about the purpose and benefits of medications.

Collaborating with the client to develop a medication regimen that fits their lifestyle and preferences.

Regularly assessing medication adherence and addressing any barriers to compliance.

Offering support and encouragement to the client throughout the treatment process.

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A nurse is in the day room of an acute care mental health facility with a group of clients who are watching television. Suddenly, one of the clients jumps up screaming and runs out of the room. What should the nurse do next?

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A nurse is in the day room of an acute care mental health facility with a group of clients who are watching television.

Suddenly, one of the clients jumps up screaming and runs out of the room.

What should the nurse do next?