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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

(A) Explain that these beliefs are related to her illness:While it is important to educate the client about their illness, directly challenging their delusions may increase distrust and anxiety. This approach might make the client feel misunderstood and less likely to trust the nurse.

(B) Explain that distrust is related to feeling anxious:This explanation might not be well-received by the client and could be perceived as dismissive of their concerns. It may not effectively address the client’s immediate need for trust and reassurance.

(C) Initiate short, frequent contacts with the client:This approach helps build trust through consistent and reliable interactions. It allows the nurse to establish a rapport without overwhelming the client, thereby promoting a sense of safety and trust. Regular, brief interactions can help the client feel more comfortable and secure.

(D) Offer to keep the belongings at the nurse’s desk:This action might be perceived as an attempt to take control of the client’s belongings, which could reinforce their delusions and decrease trust. It is important to respect the client’s need to keep their belongings close to them.

A. Return at a later time to talk. B. Ask a different question. C. Wait for the client to respond. D. Ask if the client heard the question.

Correct Answer is C

Explanation

A) Returning at a later time to talk might seem considerate, but it may miss the opportunity to engage with the client in the moment. The client may benefit from having the nurse's presence and support, even if they are slow to respond.

B) Asking a different question could disrupt the process and prevent the client from expressing their feelings. It’s important to allow the client the space to answer the original question rather than shifting topics prematurely.

C) Waiting for the client to respond is the best action. This approach demonstrates patience and respect for the client's current state. By allowing time for a response, the nurse can create a supportive environment, which may help the client feel more comfortable opening up when they are ready.

D) Asking if the client heard the question might feel like an interruption or could add pressure, making the client more anxious. It’s better to give the client space to process and respond without feeling judged or rushed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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