An adolescent male who was arrested a month ago for gang-related activities has a court order to attend weekly group therapy sessions at the mental health clinic. Today his mother calls the clinic nurse to report that her son became angry last night and put his fist through a window. Which intervention is most important for the nurse to implement?

Advise the mother to call the police if violent behavior occurs again.

Refer the mother for psychiatric evaluation for anxiety and depression.

Reinforce the need for the adolescent to attend group therapy sessions.

Tell the mother to describe her feelings of helplessness to her son.

Answer and Explanation

The Correct Answer is A

A.   Advising the mother to call the police if violent behavior occurs again addresses the safety of the client and others and is a necessary step to ensure appropriate intervention.
B.   Referring the mother for psychiatric evaluation is important but may not directly address the immediate safety concern related to the recent violent behavior.
C. Reinforcing the need for the adolescent to attend group therapy sessions is relevant, but the immediate focus should be on addressing the safety issue.
D.   Telling the mother to describe her feelings may be helpful for therapeutic communication but may not be the most urgent intervention in response to the reported violent behavior.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Inquiring about the client’s support system may be important, but the immediate concern is the statement indicating a potential risk of harm.
B. Asking the client to repeat the comment may not be as effective as taking immediate action to prevent harm.
C. Stopping the client from leaving the ED is the priority to ensure the client's safety and prevent the potential act of self-harm.
D. Recording the statement in the client's chart is important but should be done after taking immediate action to address the potential risk.

A. Explain to the client that her behavior invades the rights of the nursing staff. B. Teach the client strategies to control her obsessive-compulsive behavior. C. Ask the client to explain why she is keeping a detailed record of her nursing care. D. Encourage the client to express her feelings regarding the upcoming procedure. E. None F. None

Correct Answer is D

Explanation

A. Explain to the client that her behavior invades the rights of the nursing staff: This approach is confrontational and dismisses the client’s coping mechanism. It does not promote a therapeutic nurse-client relationship.

B. Teach the client strategies to control her obsessive-compulsive behavior: This is not the appropriate time for teaching behavioral strategies, especially when the client is experiencing stress related to an upcoming invasive procedure.

C. Ask the client to explain why she is keeping a detailed record of her nursing care: While this might offer insight, it can come across as intrusive or judgmental. It also shifts the focus away from emotional support.

D. Encourage the client to express her feelings regarding the upcoming procedure: Clients with obsessive-compulsive personality disorder often rely on control and orderliness to manage anxiety. The nurse should recognize that the client’s behavior may be a coping mechanism for procedure-related stress. Encouraging expression of feelings promotes trust and addresses the underlying anxiety.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is D

Explanation

Naloxone is administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate. Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?

An adolescent who is a heroin addict is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?

A client with opioid dependence makes a statement to the nurse about desiring to lead a healthier lifestyle by making changes in the next 2 weeks. How should the nurse respond?

The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client’s tongue is “worming”. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?

The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client’s history should the nurse further explore?

The nurse is initiating an interview with a client in the emergency department who presents with a fractured ulna and swollen, red lips and nose. The client's spouse is pacing outside the door of the examination room. Which action should the nurse take?

The nurse is leading a group on the inpatient psychiatric unit. Which approach should the nurse use during the working phase of group development?