A nurse on a mental health unit enters the day room and observes a client hit another client. Which of the following statements should the nurse make?

"I'm taking away your TV privileges and putting you in seclusion."

"Hitting others is unacceptable behavior."

"Your behavior will disappoint your provider."

"Why did you hit another client?"

Answer and Explanation

The Correct Answer is B

Choice A reason:
Taking away TV privileges and placing the client in seclusion could be perceived as punitive rather than therapeutic. It may escalate the situation and does not address the immediate need to ensure safety and de-escalate the aggression.

Choice B reason:
Stating that hitting others is unacceptable is a clear and direct way to address the behavior. It sets a firm boundary and communicates the expectations for behavior within the unit, which is essential in managing aggressive situation.

Choice C reason:
Saying that the behavior will disappoint the provider personalizes the issue and may not be effective in the moment. The focus should be on the immediate safety of all clients and the unacceptability of the behavior, rather than on the potential emotional response of the provider.

Choice D reason:
Asking why the client hit another client immediately after the incident may not be productive and could lead to further justification of the behavior or additional aggression. It's important to first address the behavior and ensure safety before exploring the reasons behind it.

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Correct Answer is D

Explanation

Choice A reason:

Stop the car in the client’s driveway and call the authorities. This statement is wrong because stopping in the driveway could escalate the situation and put the nurse in immediate danger. The nurse should avoid any actions that might provoke the client or put herself in harm’s way.

Choice B reason:

Honk the car horn to get the client’s attention. This statement is wrong because honking the horn could startle the client, potentially leading to a violent reaction. Sudden loud noises can exacerbate agitation in individuals with schizophrenia.

Choice C reason:

Calmly speak the client’s name out of the car window. This statement is wrong because engaging with the client directly while they are armed is unsafe and could provoke aggression. The nurse should avoid direct interaction until the situation is secured.

Choice D reason:

Keep driving in a path that is going away from the client’s house. This is the correct action as it ensures the nurse’s safety by distancing herself from the potentially dangerous situation. Once at a safe distance, the nurse can contact the authorities for assistance.

A. The client is unwilling to accept that treatment is needed. B. The client states that she plans to move out of the state immediately. C. The client states that she does not like the neighbor. D. The client is a danger to herself or others.

Correct Answer is D

Explanation

Choice A reason:
An unwillingness to accept that treatment is needed is not, by itself, a condition that can legally justify extending a hospital hold beyond the initial 72 hours. Treatment refusal can be a complex issue and may require a deeper understanding of the client's capacity to make informed decisions.

Choice B reason:
The client's intention to move out of the state does not constitute a legal basis for extending a hospital hold. The focus of continued hospitalization would be on immediate safety concerns rather than future living arrangements.

Choice C reason:
Disliking a neighbor is not a condition that warrants an extended hospital hold. Personal feelings or disputes do not equate to a risk that justifies involuntary hospitalization.

Choice D reason:
If the client poses a danger to themselves or others, this is a condition under which the hospital can legally extend the hold beyond 72 hours. The primary concern is the safety of the client and those around them, and if there is a risk of harm, the client may be held involuntarily until it is deemed safe for them to be discharged.

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A nurse on a mental health unit enters the day room and observes a client hit another client. Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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