A nurse is leading a group therapy session. A client with a history of violence suddenly stands up and appears angry. Which of the following actions should the nurse take?

Place the client in mechanical restraints.

Ask the client to describe how they are feeling

Stand directly in front of the client when speaking to them.

Use therapeutic touch when addressing the client.

Answer and Explanation

The Correct Answer is B

A. Place the client in mechanical restraints: Restraints should only be used as a last resort and only when the client poses an immediate risk to themselves or others. The first priority should be to try to de-escalate the situation verbally.

B. Ask the client to describe how they are feeling: This is the most appropriate intervention. Asking the client to express their emotions helps acknowledge their feelings and can de-escalate the situation. This approach is non-threatening and allows the nurse to assess the client's state and intervene appropriately.

C. Stand directly in front of the client when speaking to them: Standing directly in front of the client can be perceived as confrontational, especially when the client is angry. It is better to stand at an angle to the client, maintaining a non-threatening stance.

D. Use therapeutic touch when addressing the client: Therapeutic touch may escalate the situation, especially if the client is already angry. It is important to maintain a safe distance and avoid physical contact until the client’s emotional state is more stable.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

Rationale for correct choices:

Remaining neutral: The nurse should remain neutral to avoid reinforcing or escalating the client’s grandiose beliefs. This helps maintain trust and creates space for self-reflection without judgment.
Explaining that the client is not entitled to play on a professional team: Gently addressing the client’s unrealistic expectations helps them understand the reality of their situation and fosters a more grounded perspective on their goals.

Rationale for incorrect choices:

Questioning the client's abilities: Directly questioning the client's abilities could be seen as confrontational and may increase defensiveness. A more constructive approach would focus on challenging unrealistic beliefs.
Challenging the client's feelings of grandiosity: Challenging grandiosity directly can make the client feel attacked. It’s better to educate and explain the reality of their expectations in a supportive way.
Supporting the client's fear of abandonment: The client does not appear to express abandonment fears in this case. The issue is more related to grandiosity, so focusing on this would be more effective.
Suggesting another sport: Suggesting a different sport might divert attention from the core issue—grandiosity. Addressing the client's distorted self-image is more important before offering alternatives.

A. Intellectualization B. Introjection C. Rationalization D. Repression

Correct Answer is C

Explanation

A. Intellectualization: Intellectualization involves using logic or reasoning to avoid emotional response to stress, but it is not the defense mechanism demonstrated here. The client is not using abstract thinking to avoid feelings but justifying behavior.

B. Introjection: Introjection involves internalizing the beliefs or values of others, which is not what is happening in this scenario. The client is not adopting someone else’s values but rationalizing their own actions.

C. Rationalization: Rationalization is the defense mechanism the client is using. The client is justifying their drinking as a way to cope with stress, making the behavior seem reasonable or acceptable even though it may be harmful.

D. Repression: Repression involves unconsciously blocking out uncomfortable thoughts or feelings, but the client is not denying their emotions or thoughts about stress. Instead, they are justifying their behavior, which aligns more with rationalization.

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A nurse is leading a group therapy session. A client with a history of violence suddenly stands up and appears angry. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the student health clinic is caring for a client Exhibits Complete the following sentence by using the lists of options. The nurse should care for the client by dropdownanddropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}

Explanation

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Correct Answer is C

Explanation

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