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 B

Explanation

A. An assistive personnel reapplies a soft limb restraint on a client after assisting them to the bathroom: Reapplying a soft limb restraint in itself does not necessarily require an incident report. However, the application must follow proper protocols, and the nurse should ensure that the assistive personnel are trained and following the correct procedures.
B. An assistive personnel applies physical restraints on a client who is aggressive: Physical restraints should only be applied with a physician's order and in accordance with facility policies. If restraints are applied without proper authorization or protocol, an incident report must be completed.
C. An assistive personnel tells the provider that a client is making other clients feel unsafe: Reporting concerns to the provider about a client's behavior is part of proper communication and does not require an incident report.
D. An assistive personnel provides 1:1 monitoring for a client who is reporting thoughts of self-harm: This is an appropriate and necessary intervention for a client at risk of self-harm. It does not require an incident report, as the staff member is performing their duty to ensure the safety of the client.

A. Encourage the client to take naps during the day B. Install locks at the bottom of the exit doors. C. Place the client's mattress on the floor. D. Place rubber-backed throw rugs on tile floors.

Correct Answer is B

Explanation

A. Encourage the client to take naps during the day: While daytime napping may help the client rest, it is unlikely to directly prevent nighttime wandering. It might even interfere with nighttime sleep, potentially increasing wandering behavior.
B. Install locks at the bottom of the exit doors: Installing locks at the bottom of exit doors is an effective safety intervention. It can prevent the client from wandering outside while still allowing caregivers to monitor and assist the client if needed.
C. Place the client's mattress on the floor: Placing the mattress on the floor might prevent injury if the client falls out of bed, but it does not address the core issue of nighttime wandering. Additional measures are needed to manage wandering safely.
D. Place rubber-backed throw rugs on tile floors: Rubber-backed throw rugs can help prevent slipping but do not directly address the issue of wandering. This intervention may be useful for fall prevention but not for preventing the client from wandering at night.

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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

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