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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
A client exhibiting psychotic behavior may not be the best candidate for group therapy initially, as they might be experiencing delusions, hallucinations, or disorganized thinking that could disrupt the group process and might not be able to participate effectively. Individual therapy might be more appropriate until the client's symptoms are better managed.
Choice B Reason:
A client who was admitted 5 hours ago for acute mania is likely still experiencing heightened levels of energy, impulsivity, and possibly erratic behavior. They may not be able to engage in group therapy effectively and could benefit from stabilization before participating in a group setting.
Choice C Reason:
A client who has been taking lithium for 2 weeks for depression is likely to have achieved some level of stabilization of their mood. Lithium is a mood stabilizer used to treat bipolar disorder and depression, and after 2 weeks, the client may be ready to engage with others in a therapeutic group setting.
Choice D Reason:
A client who is in a manic state, similar to the client in choice B, may not be suitable for group therapy due to potential disruptive behavior and difficulty focusing on the group process. It's important for the client to receive individual attention to manage the mania before joining group therapy.
Question 43
Correct Answer is B
Explanation
Choice A reason:
Waiting for the client to initiate interaction may result in missed opportunities to build trust and rapport. Clients who are suspicious may never feel comfortable enough to initiate interaction, which could hinder their care and treatment.
Choice B reason:
Adopting a neutral attitude when providing care is recommended for clients who are suspicious. It helps to establish a non-threatening environment and conveys a sense of respect for the client's need for space and boundaries.
Choice C reason:
Disclosing personal information to demonstrate approachability can backfire with clients who are suspicious. It may be perceived as intrusive or as an attempt to elicit personal information from them in return.
Choice D reason:
Approaching the client frequently throughout the day for brief interactions might overwhelm and increase the client's suspicion. It's important to respect the client's space and allow them to set the pace for interactions.
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