A nurse is preparing to change the dressing on the lower leg of an older adult client who is in a wheelchair, and has a history of maladaptive coping skills. The client begins swearing at and verbally abusing the nurse. Which of the following actions should the nurse take?

Explain to the client why her behavior is inappropriate.

Tell the client when he will return and leave the room.

Place wrist restraints on the client to prevent psychomotor agitation.

Move the client to a seclusion room.

Answer and Explanation

The Correct Answer is B

By calmly informing the client when the nurse will return and then leaving the room, the nurse establishes clear boundaries and removes themselves from the situation to ensure their own safety. It allows the nurse to disengage from the abusive behavior and avoid escalating the situation further.

Let's review the other options and explain why they are not appropriate in this situation:

A. Explaining to the client why their behavior is inappropriate may not be effective in the moment when the client is already agitated and verbally abusive. Attempting to reason with or educate the client during this state could potentially escalate the situation or prolong the abusive behavior.

C. Placing wrist restraints on the client should only be done in exceptional circumstances when there is an imminent risk of harm to themselves or others. Verbal abuse, while unpleasant, does not necessarily warrant the use of restraints as a first-line intervention.

D. Moving the client to a seclusion room is also an extreme measure and should only be considered if the client's behavior poses a significant risk to themselves or others and less restrictive interventions have been exhausted. Verbal abuse alone would not typically warrant seclusion.

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Correct Answer is C

Explanation

The perception of family can vary among individuals, and it is important to respect the client's definition of family. By including people whom the client views as family, the nurse acknowledges the client's preferences and ensures that those who hold significance and provide support in the client's life are present during the interview.

Let's review the other options and explain why they may not be the most appropriate methods:

A. Include people who can support the client adequately: While it is important to involve individuals who can support the client, determining who can provide adequate support should be based on the client's perception and preference. The client's perspective on who can offer support may differ from the nurse's assessment, so it is crucial to involve individuals whom the client identifies as supportive.

B. Include people who live in the same house with the client: Proximity of residence does not necessarily determine the level of support or the client's perception of family. Including only individuals who live with the client may exclude other significant individuals in the client's life who may play a vital role in their support network.

D. Include people who are related to the client by blood and marriage: While blood relatives and family members by marriage can be important sources of support, it is not the sole criterion for inclusion. Clients may have chosen family or close friends who they consider to be their primary support system.

A. "It must be very difficult for you to see your wife in pain." B. "We're doing everything we can to keep your wife comfortable." C. "I wish there was more that I could do to relieve your wife's pain, too." D. "I'm sure your wife will begin to feel better soon."

Correct Answer is A

Explanation

The appropriate response for the nurse in this situation is to acknowledge the partner's concern and empathize with their feelings. By stating, "It must be very difficult for you to see your wife in pain," the nurse acknowledges the partner's emotions and shows understanding and empathy. This response validates the partner's feelings and demonstrates support and compassion.

B- "We're doing everything we can to keep your wife comfortable" may be a true statement, but it does not directly address the partner's expressed wish to do something to help. It may not fully address the emotional aspect of the partner's statement.

C- "I wish there was more that I could do to relieve your wife's pain, too" is a genuine response that expresses empathy. It acknowledges the partner's desire to help and implies that the nurse shares the same sentiment. This response shows understanding and support.

D- "I'm sure your wife will begin to feel better soon" dismisses the partner's concern and does not address their expressed wish to alleviate their wife's pain. It may not fully acknowledge the partner's emotions or provide the support they need in that moment.

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A nurse is preparing to change the dressing on the lower leg of an older adult client who is in a wheelchair, and has a history of maladaptive coping skills. The client begins swearing at and verbally abusing the nurse. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning an Interview for a newly admitted client and plans to Include the client's family members. Which of the following methods should the nurse use to determine who to include in the interview?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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A nurse is preparing to change the dressing on the lower leg of an older adult client who is in a wheelchair, and has a history of maladaptive coping skills. The client begins swearing at and verbally abusing the nurse. Which of the following actions should the nurse take?

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