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 B

Explanation

Choice A rationale:

While encouraging decision-making can be empowering for some individuals with depression, it may not be appropriate for those with severe depressive disorder.

Individuals with severe depression often experience significant anhedonia (loss of interest in activities), fatigue, and difficulty concentrating, which can make decision-making overwhelming and even worsen their symptoms.

It's important to assess the client's individual level of functioning and decision-making capacity before implementing this intervention.

Choice C rationale:

Providing a selection of activities can be helpful, but it's crucial to tailor the activities to the client's interests and energy level.

Offering too many choices or activities that are too demanding can be counterproductive.

It's essential to collaborate with the client to identify activities that are meaningful and achievable, and to gradually increase the level of activity as tolerated.

Choice D rationale:

Playing a game of chess can be a stimulating and enjoyable activity, but it may not be appropriate for all clients with severe depression.

Chess requires cognitive focus and strategic thinking, which can be challenging for individuals experiencing cognitive impairment or fatigue associated with depression.

It's important to assess the client's cognitive abilities and interests before suggesting this activity.

Rationale for the correct answer, B:

Spending time with the client offers several benefits:

Conveys caring and support: It demonstrates to the client that they are not alone and that someone cares about their wellbeing.

Provides opportunities for therapeutic communication: Spending time together allows for meaningful conversations, which can help the client express their feelings, concerns, and experiences.

Facilitates observation and assessment: The nurse can observe the client's mood, behavior, and interactions, which can inform treatment planning and evaluation.

Promotes engagement and participation: Spending time with the client can encourage them to engage in other therapeutic activities and interventions.

Builds rapport and trust: Developing a strong therapeutic relationship is essential for effective treatment of depression.

A. The client has lost 10 lb. B. The client visits his partner’s grave each month. C. The client has been unable to return to work. D. The client has difficulty sleeping

Correct Answer is C

Explanation

Choice A rationale:

Losing 10 lb after the death of a loved one is not uncommon, especially within the first few months of grieving. It can be due to decreased appetite, changes in eating habits, or increased physical activity. While it's important to monitor weight loss and ensure adequate nutrition, it doesn't necessarily indicate maladaptive grieving on its own.

Grief can often lead to changes in appetite and weight. Some people may experience a loss of appetite and unintentional weight loss, while others may find themselves overeating or gaining weight. These changes are often temporary and subside as the grieving process progresses.

It's important to consider the client's overall health and well-being when assessing weight loss. If the client is experiencing significant weight loss, it's important to rule out any underlying medical conditions that may be contributing to it.

Choice B rationale:

Visiting a loved one's grave is a common way to grieve and remember them. It can be a way to feel connected to the deceased, express love and sorrow, and find solace. It's a normal part of the grieving process and doesn't necessarily indicate maladaptive grieving.

Grieving individuals often find comfort in visiting the gravesite of their loved one. It can be a place to reflect, remember, and feel close to the deceased. Visiting a gravesite can also be a way to honor the loved one's memory and express continued love and respect.

The frequency of grave visits can vary from person to person. Some individuals may visit frequently, while others may only visit on special occasions or anniversaries. There is no right or wrong way to grieve, and what matters most is that the individual finds a way to express their grief in a way that feels right for them.

Choice D rationale:

Difficulty sleeping is a common symptom of grief. It can be caused by a variety of factors, including anxiety, sadness, and changes in sleep patterns. While it can be distressing, it's not always a sign of maladaptive grieving.

Grief can disrupt sleep patterns in a number of ways. It can make it difficult to fall asleep, stay asleep, or both. It can also lead to nightmares, night sweats, and early morning awakenings. These sleep disturbances can be both physically and emotionally draining.

There are a number of things that can be done to improve sleep during grief. These include establishing a regular sleep schedule, creating a relaxing bedtime routine, avoiding caffeine and alcohol, and getting regular exercise. If sleep problems persist, it's important to seek professional help.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the care plan for a newly admitted client suffering from severe depressive disorder. Which of the following interventions should the nurse incorporate into the plan?

Correct Answer is B

Explanation

A nurse is collecting data from a middle-aged client whose partner died seven months ago. Which of the following findings indicate that the client is experiencing maladaptive grieving?

Correct Answer is C

Explanation

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A nurse is contributing to the plan of care for a newly-admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse plan to include?

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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?