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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Free Nursing Study Resources

Correct Answer is A

Explanation

Memory loss is a known side effect of electroconvulsive therapy (ECT), particularly in the short term. It is important for the nurse to provide accurate information to the client about this

potential side effect. Assuring the client that memory loss is common and tends to improve over time can help alleviate their concerns and provide reassurance. It is important to convey that this is a temporary effect and not necessarily indicative of long-term memory problems.

The other options are not appropriate responses:

B. "You will likely experience long-term memory loss as well": This statement provides inaccurate and potentially alarming information. While some individuals may experience persistent memory issues, it is not appropriate to assume or predict long-term memory loss in every case.

C. "You should focus on how much better you feel": This response dismisses the client's concerns about memory loss and may not address their needs or worries adequately. It is important to acknowledge and validate the client's experience.

D. "I am going to notify your provider about your memory loss": While it is important for the nurse to communicate any concerning symptoms to the client's healthcare provider, simply stating this without providing further information or reassurance may increase the client's anxiety without addressing their immediate concerns about memory loss.

A. Suppression B. Intellectualization C. Dissociation D. Projection

Correct Answer is D

Explanation

Projection is a defense mechanism where an individual attributes their own thoughts, feelings, or impulses onto someone else. In this case, the client is attributing the cause of their drug use to their parents not allowing them to get a tattoo. By projecting their desire for a tattoo onto their parents' decision, the client is displacing their own feelings onto an external factor.

Incorrect:

A. Suppression: Suppression involves consciously pushing away or blocking unwanted thoughts, feelings, or impulses. The client's statement does not indicate an attempt to suppress any thoughts or emotions related to their drug use; instead, they are openly discussing the reason for their substance use.

B. Intellectualization: Intellectualization involves using excessive reasoning or logic to avoid acknowledging or experiencing associated emotions. The client's statement does not reflect intellectualization, as they are not overly relying on intellectual processes or attempting to detach themselves from the emotional aspects of their behavior.

C. Dissociation: Dissociation involves a temporary disconnection from thoughts, feelings, or memories to avoid emotional distress. The client's statement does not demonstrate dissociation, as they are connecting their drug use to a specific event and cause.

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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 caring for a client who has received nine electroconvulsive therapy (ECT) treatments and reports short-term memory loss. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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