An older adult woman who lives in a long-term mental health facility has a history of taking belongings from other clients' rooms when she becomes agitated. The client is found placing these items in the same closet on the unit. Which action should the nurse take?
Tell the client that it is important to respect others' belongings.
Take away privileges until the behavior is extinguished.
Nothing, her action is not harmful to others.
Remove the client from these areas when she is agitated.
The Correct Answer is D
A) Telling the client that it is important to respect others' belongings may be a valid point, but it does not address the immediate behavior and does not provide a practical solution. Simply stating this may not help the client understand the consequences of her actions or modify her behavior.
B) Taking away privileges until the behavior is extinguished can lead to feelings of punishment and may not be effective in changing the behavior. It is essential to approach the situation with understanding rather than punitive measures.
C) Doing nothing is not an appropriate response. While the behavior may not be physically harmful, it can disrupt the community and the therapeutic environment of the facility. It is important to address the behavior proactively.
D) Removing the client from these areas when she is agitated is the most appropriate action. This intervention helps to prevent the behavior from occurring and allows the nurse to manage the client’s agitation in a constructive way. It provides an opportunity to redirect her focus and reduce her agitation, promoting a safer environment for all clients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) While understanding the reason for the suicide attempt can provide important context, it is not as critical in the immediate management of a suspected overdose as knowing the specifics of what was ingested.
B) Identifying the drug that was ingested is the most important information for the nurse to obtain. Knowing the specific substance allows for appropriate and timely treatment, including the administration of antidotes if applicable and understanding potential complications.
C) The time since drug ingestion is also relevant, as it can influence treatment decisions and urgency. However, without knowing the specific drug, it may be challenging to determine the best course of action.
D) A past history of depression is important for the overall understanding of the client's mental health, but it does not have immediate implications for managing an overdose. The priority is to address the acute medical situation first.
Correct Answer is A
Explanation
A) Becoming the faculty sponsor for Students Against Drunk Driving (SADD) is a proactive and constructive behavior that indicates the client is coping well with her anxiety related to the student’s death. This action demonstrates her ability to channel her grief into positive advocacy, suggesting that she is processing her emotions and seeking to create meaningful change, which is a strong indicator of healthy coping.
B) Describing alternatives to becoming depressed over the student’s death is a positive step, as it shows the client is engaging in cognitive strategies to manage her emotions. However, while this indicates some progress, it is less impactful than taking active steps to address the issue, like becoming involved in advocacy or community efforts.
C) Confronting her parents about the hurt she felt as a child of alcoholic parents can be a significant therapeutic step, but it may not directly relate to her current coping with the loss of her student. While this confrontation may contribute to her overall healing, it does not necessarily indicate coping specifically related to the anxiety from the recent event.
D) Signing a safety contract with the nurse indicates that there may still be significant concerns regarding self-harm or emotional distress. While this is an important safety measure, it suggests that the client is not yet fully coping well with her anxiety, as it implies she is still in a vulnerable state rather than demonstrating effective coping mechanisms.
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