A nurse on a mental health unit notices that a client is becoming increasingly agitated and throws a table when he is unable to select the television (TV) channel. Which of the following should be a priority action by the nurse?

Attempt to talk the client down.

Administer a PRN antianxiety medication.

Place the client in a monitored seclusion room until he is calm.

Restrain the client to prevent injury to himself or others.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Attempting to talk the client down is the priority action in this situation. Agitation can escalate to aggression or violence if not addressed appropriately. Engaging in therapeutic communication can help de-escalate the client's agitation, express understanding, and potentially find out the underlying cause of their distress. This approach prioritizes a non-pharmacological intervention.

Choice B rationale:

Administer a PRN antianxiety medication. While medication might be a consideration for managing agitation, it's generally not the first action to take. Non-pharmacological interventions, like therapeutic communication, should be attempted first to minimize the reliance on medications to manage behaviors.

Choice C rationale:

Place the client in a monitored seclusion room until he is calm. Placing a client in seclusion should be a last resort and should only be done when there's an immediate risk of harm to the client or others. In this scenario, the client's agitation doesn't seem to present an imminent danger, so seclusion would be an excessive and restrictive intervention.

Choice D rationale:

Restrain the client to prevent injury to himself or others. Restraint should be an absolute last resort and only used when there's an imminent risk of harm that cannot be managed in any other way. Restraint can escalate agitation and trauma for the client, as well as pose legal and ethical concerns. Therefore, it should only be used when all other options have been exhausted and safety is a critical concern.

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Correct Answer is B

Explanation

The correct answer is choice B: "Tell me more about your concerns about taking chemotherapy."

Choice A rationale:

This response focuses on negative outcomes and might discourage the client from exploring her options. It does not support the client's autonomy or address her concerns about nontraditional treatments. The nurse's role should be to facilitate open communication and understanding.

Choice B rationale:

This response is the most therapeutic. By inviting the client to share her concerns, the nurse demonstrates empathy and encourages the client to express her thoughts and feelings. This approach fosters a collaborative and respectful relationship, allowing the nurse to address the client's worries effectively.

Choice C rationale:

This response is directive and dismissive of the client's wishes. It fails to consider the client's perspective and autonomy. The nurse should avoid imposing personal opinions and instead promote a patient-centered approach.

Choice D rationale:

While acknowledging the provider's expertise is important, this response does not address the client's concerns about nontraditional treatments. It's essential to focus on the client's individual preferences and provide information to help her make an informed decision.

A. "Tell me what is concerning you.” B. "Crying helps us let things out and we feel better.” C. "Your husband is making really good progress.” D. "Did your husband say something to upset you?”

Correct Answer is A

Explanation

Choice A rationale:

The correct choice. In this situation, the nurse's priority is to gather information and provide emotional support. By asking the spouse to share their concerns, the nurse opens up a channel of communication and shows empathy, creating an opportunity to address the spouse's worries and provide reassurance.

Choice B rationale:

While the sentiment that crying can be cathartic and relieving is true, this response does not directly address the spouse's concern or encourage them to share their feelings. It's important to focus on the spouse's feelings rather than just explaining the benefits of crying.

Choice C rationale:

Assuming that the husband is making progress without knowing the specifics of the situation can come across as dismissive of the spouse's concerns. It's important to validate the spouse's emotions and provide support, rather than making assumptions about the husband's progress.

Choice D rationale:

Asking whether the husband said something to upset the spouse might be relevant, but it does not address the spouse's expressed concern about their husband. This response may not foster open communication and emotional support as effectively as choice A.

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A nurse on a mental health unit notices that a client is becoming increasingly agitated and throws a table when he is unable to select the television (TV) channel. Which of the following should be a priority action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While in group therapy, a nurse is caring for a client who has cancer and is scheduled for immediate chemotherapy. The client tells the nurse that she wants to try nontraditional treatments first. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse observes a client's spouse sitting alone in the waiting room crying. When approached, the spouse says, "I am really concerned about my husband." Which of the following is an appropriate response by the nurse?

Correct Answer is A

Explanation

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