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. Client withdrawal of prior consent must be done in writing: While clients can withdraw consent, it does not always need to be done in writing, depending on the situation. Verbal withdrawal is often sufficient unless specified otherwise.

B. Clients can refuse to attend group therapy: Clients have the right to refuse treatments and therapies, including group therapy, unless they pose a direct threat to themselves or others. This is part of respecting client autonomy.

C. Clients who are involuntarily committed do not maintain access to legal counsel: Clients who are involuntarily committed still have the right to access legal counsel. They have the right to challenge their commitment and consult with an attorney.

D. Clients who have a severe mental illness cannot request a psychiatric advance directive: Clients, regardless of the severity of their mental illness, can request a psychiatric advance directive. This document helps ensure that their treatment preferences are known if they are unable to communicate them during a crisis.

A. Call security guards to the scene for a show of force. B. Escort the client to a secluded area to speak privately. C. Offer the client several options for a time-out period. D. Place the client in restraints before they escalate further.

Correct Answer is C

Explanation

A. Call security guards to the scene for a show of force: Calling security may escalate the situation, especially if the client is already showing signs of agitation. This could increase fear or aggression, making it harder to de-escalate the client. A calm and supportive approach is more effective.
B. Escort the client to a secluded area to speak privately: Escorting the client to a secluded area may increase feelings of isolation or entrapment, potentially worsening the situation. It is better to maintain an open, non-threatening environment for communication and de-escalation.
C. Offer the client several options for a time-out period: Offering choices, such as a time-out, helps the client feel some control over the situation, which can reduce agitation. This strategy fosters cooperation while addressing the need for the client to calm down in a safe space.
D. Place the client in restraints before they escalate further: Restraints should be a last resort and only used if the client poses an immediate danger to themselves or others. Using restraints prematurely can increase aggression and escalate the situation, so other de-escalation techniques should be tried first.

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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?

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