A patient sits in silence for 20 minutes after a therapy appointment, appearing tense and vigilant. The patient abruptly stands and paces back and forth, clenching and unclenching fists, and then stops and stares in the face of a staff member. What is the likely conclusion regarding the patient's behavior?

Patient is attempting to use relaxation strategies.

Patient is demonstrating withdrawal behaviors.

Patient is exhibiting clues to potential aggression.

Patient is trying to work through angry feelings.

Answer and Explanation

The Correct Answer is C

A.   Relaxation strategies involve deliberate and often structured activities aimed at reducing tension and stress, which isn't depicted in the described behavior.
B.   Withdrawal behaviors typically involve avoiding social interaction or retreating, which doesn't align with the observed actions.
C.   The described behavior, including pacing, clenching fists, and staring at a staff member, indicates potential signs of aggression or agitation.
D.   Working through angry feelings might involve communication or expression of emotions, but the described behavior leans more towards agitation and potential aggression.

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Correct Answer is C

Explanation

A. Providing medications against a patient's will generally requires a legal process or evaluation of capacity rather than a blanket statement of administration.
B. Clients who are involuntarily admitted might not have the right to refuse treatment initially based on the nature of the admission.
C. Involuntary admissions often allow for extended hospitalization based on the judgment of the treatment team.
D. Laws regarding restraints are generally consistent regardless of the mode of admission, focusing on safety and necessity rather than the mode of admission.

A. Call for assistance to place the client in restraints. B. Escort the client to an unlocked seclusion room. C. Speak to the client calmly, giving simple directions. D. Offer the client a PRN antianxiety medication.

Correct Answer is C

Explanation

A. Restraining the client should be a last resort and is not the initial action to take when managing an agitated client.
B. Seclusion should also be considered as a last resort, and de-escalation techniques should be attempted before secluding the client.
C. Speaking calmly and providing simple directions can help de-escalate the situation by promoting a calm environment and reducing stimuli that may exacerbate the client's agitation.
D. While medication might be necessary in some cases, it's not the first action to take when a client becomes agitated.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager on a mental health unit is discussing involuntary admissions during a staff meeting. Which of the following statements should the manager include in the discussion?

Correct Answer is C

Explanation

A nurse in an acute mental health facility is caring for a client who jumps out of her chair and begins to shout angrily at the clients around her. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A charge nurse is conducting a staff education in-service about depressive disorders. Which of the following should the nurse identify as a risk factor for depression?

A patient cries as the nurse explores the patient's relationship with a deceased parent. The patient says, "I shouldn't be crying like this. It happened a long time ago." Which responses by the nurse will facilitate communication? (Select all that apply.)

After failing two tests, a college student cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate. Which behavior provides the strongest clue of an impending suicide attempt?

When assessing for the subjective symptoms of posttraumatic stress disorder (PTSD), which question will the nurse ask a client hospitalized for severe anxiety related to a sexual assault by a family member as a teenager?

A soldier returns to the United States from active duty in a combat zone. The soldier is diagnosed with posttraumatic stress disorder (PTSD). The nurse's highest priority is to screen this soldier for which problem?

An individual has been diagnosed with a dissociative disorder. Which comorbid psychiatric disorders are most likely to accompany this type of mental illness? (Select all that apply.)

A nurse is providing teaching for a client who has a recent diagnosis of depression. Which of the following should the nurse identify as a primary risk factor for this disorder?

A nurse is caring for a client following a suicide attempt. The client has a history ofdepression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority?