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.

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

Explanation

Rationale for correct choices:

Administer metoclopramide 10 mg IM: The client is experiencing nausea and vomiting, and metoclopramide is an antiemetic that can help alleviate these symptoms. Managing nausea is crucial for preventing further dehydration and discomfort, especially as the client is refusing to eat or drink anything and has been vomiting most of the night.
Administer diazepam 10 mg PO: Diazepam is a benzodiazepine used to manage alcohol withdrawal symptoms, such as anxiety and the risk of seizures. It should be administered to prevent severe withdrawal symptoms and ensure the client’s safety, once nausea is managed.

Rationale for incorrect choices:

Offer ice chips and fluids: While ice chips may help with hydration, the priority is to address the nausea and alcohol withdrawal symptoms first. Administering metoclopramide is the first step to manage nausea, making fluid intake more tolerable.
Do a CBC and basic metabolic profile: These tests are important for monitoring the client’s condition but are not as urgent as managing nausea and alcohol withdrawal symptoms. These tests should be completed once the acute symptoms are addressed.
Perform alcohol use disorders identification test (AUDIT): The AUDIT is useful for assessing the severity of alcohol use disorder, but it is not an immediate priority. Managing the client's physical symptoms takes precedence before conducting assessments.
Begin substance use group therapy: Group therapy is an essential part of treatment but should not be initiated before addressing the client’s immediate physical needs, particularly nausea and alcohol withdrawal symptoms.

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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 B

Explanation

A nurse is reviewing provider prescriptions for a client who is experiencing alcohol withdrawal. Exhibits Complete the following sentence by using the lists of options. The nurse should first dropdownfollowed bydropdown.

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

Explanation

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