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 A

Explanation

A. Approach the client from the front: Approaching the client from the front is important to avoid startling them, especially if they are disoriented. It helps ensure they are aware of your presence and reduces confusion or anxiety.

B. Avoid having a structured schedule: A structured schedule is actually beneficial for clients with dementia. Routine helps provide stability and reduces anxiety by giving the client a sense of predictability and control.

C. Remove clocks from the room: Removing clocks is not recommended. Clocks can help orient the client to time and provide a sense of structure. It may be more helpful to use large clocks or calendars with clear time indicators.

D. Give detailed explanations: Giving detailed explanations may overwhelm the client, especially if they are disoriented. It’s more effective to provide simple, clear instructions and focus on one thing at a time.

A. "My boss fired me due to my frequent absence." B. "My friends frequently drink alcohol, so I do not see them anymore." C. "I have a sibling who attends Al-Anon” D. "I take care of my parent who has Wernicke-Korsakoff syndrome."

Correct Answer is C

Explanation

A. "My boss fired me due to my frequent absence": This statement indicates a lack of support in the client's work environment, rather than a positive support system. Losing a job due to alcohol use suggests strained relationships and challenges in the client's social or professional life.
B. "My friends frequently drink alcohol, so I do not see them anymore": While the client is avoiding potentially harmful relationships, this statement indicates isolation rather than a supportive network.
C. "I have a sibling who attends Al-Anon": This statement indicates that the client has a family member actively involved in a support group (Al-Anon), which is designed for families and friends of individuals with alcohol use disorders. This suggests the client has a support system in place.
D. "I take care of my parent who has Wernicke-Korsakoff syndrome": While this indicates a sense of responsibility, it does not necessarily point to a supportive relationship. The client may be struggling with caregiving without the emotional or social support they need.

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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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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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