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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Demonstrating empathy would involve acknowledging the client's feelings or beliefs, but the nurse does not validate the client's delusion or express understanding of the client's emotional state. Instead, the nurse redirects the client to the reality of the situation, which is the group therapy session.
B: The nurse's response is therapeutic because it clearly communicates the expectations of the therapy environment. By stating "it is time for group therapy and we expect everyone to attend," the nurse is providing clear, structured guidance without engaging with the delusion, which can help the client understand the reality of the situation and what is required of them.
C: Setting limits on manipulative behavior would involve addressing and curtailing attempts by the client to control or influence a situation for their own benefit. In this scenario, the client's behavior is delusional rather than manipulative, and the nurse's response does not directly set limits on manipulation but rather on adhering to the therapy schedule.
D: Using reflection would mean the nurse is mirroring the client's thoughts or feelings to help them self-reflect. However, the nurse does not reflect the client's statement but instead focuses on the expectations of the therapy program. The nurse's response does not encourage the client to reflect on their own thoughts or feelings but redirects them to the activity at hand.
Correct Answer is A
Explanation
A. Identifying the problem or clinical question is indeed the initial step in the EBP process, as it involves recognizing an issue or a gap in current knowledge or practice.
B. Reviewing effectiveness typically falls within the implementation phase of EBP, not necessarily the final step.
C. EBP emphasizes using research evidence over personal experiences to guide practice.
D. EBP involves multiple steps that typically include more than four distinct phases, such as identifying the problem, gathering evidence, implementing interventions, and evaluating
outcomes.
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