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:

Concrete thinking is a cognitive distortion characterized by a rigid and literal interpretation of events and experiences. Individuals with concrete thinking often struggle to grasp abstract concepts, metaphors, or multiple perspectives. They tend to view situations in black-and-white terms, with little room for nuance or ambiguity.

Statement A, "I am aware that each problem has only one solution," exemplifies concrete thinking in several ways:

Absolute language: The use of the phrase "each problem has only one solution" suggests a fixed and inflexible mindset. It implies that there is only one correct way to approach any given problem, disregarding the possibility of alternative solutions or perspectives.

Oversimplification: The statement reduces the complexity of problem-solving to a single, definitive answer. It fails to acknowledge the multifaceted nature of most problems, which often require creative thinking, flexibility, and consideration of multiple factors.

Lack of abstract

Intolerance of ambiguity: Concrete thinkers often experience discomfort with uncertainty or open-ended situations. They prefer clear-cut answers and definitive conclusions, which can lead to frustration and anxiety when faced with complex or ambiguous problems.

A. Encourage the client to rest with his eyes closed. B. Re-check the client in 4 hours. C. Administer the next dose as prescribed. D. Withhold the medication.

Correct Answer is D

Explanation

Choice D rationale:

Lithium toxicity is a serious and potentially life-threatening condition. It can occur when lithium levels in the blood become too high.

Blurred vision and nausea are common early symptoms of lithium toxicity.

Withholding the medication is the most important action the nurse can take to prevent further toxicity and potential harm to the client.

The nurse should immediately notify the healthcare provider of the client's symptoms and the decision to withhold the medication.

The healthcare provider will likely order a lithium level to be drawn to assess the severity of the toxicity.

Depending on the results of the lithium level, the healthcare provider may order other interventions, such as intravenous fluids or medications to lower the lithium level.

Choice A rationale:

Encouraging the client to rest with his eyes closed may provide some temporary relief from the blurred vision, but it does not address the underlying problem of lithium toxicity.

It is important for the nurse to take more decisive action to prevent further toxicity.

Choice B rationale:

Re-checking the client in 4 hours may delay necessary interventions and allow the lithium toxicity to worsen.

It is important for the nurse to take immediate action to protect the client's health.

Choice C rationale:

Administering the next dose of lithium as prescribed would further increase the lithium level in the blood and could lead to more severe toxicity.

This is not a safe or appropriate action for the nurse to take in this situation.

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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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Correct Answer is A

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Correct Answer is D

Explanation

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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?