During a one-to-one session, the nurse begins to become angry with the client. Which action should the nurse take?

Identify the client's transference of feelings of annoyance.

Resolve the feelings with the client after discharge.

Share similar experiences the nurse has had in the past.

Terminate the session before the feelings escalate.

Answer and Explanation

The Correct Answer is D

Choice A reason: Identifying transference assumes the client’s behavior caused the nurse’s anger, which may not be accurate. Terminating the session prevents untherapeutic escalation, allowing the nurse to regain composure. This choice risks misattributing emotions, making it incorrect for managing the nurse’s immediate anger.

Choice B reason: Resolving feelings after discharge delays addressing the nurse’s current anger, risking unprofessional behavior during the session. Terminating the session maintains therapeutic boundaries, making this incorrect, as it postpones action needed to manage the immediate emotional reaction effectively.

Choice C reason: Sharing personal experiences is untherapeutic and shifts focus from the client, potentially worsening the nurse’s anger. Terminating the session preserves professionalism and boundaries, making this incorrect, as self-disclosure does not address the nurse’s emotional state or maintain a therapeutic environment.

Choice D reason: Terminating the session before anger escalates allows the nurse to regain composure, preserving therapeutic boundaries and preventing unprofessional behavior. This action prioritizes client care and nurse self-awareness, aligning with psychiatric nursing ethics, making it the best choice for managing the nurse’s emotions.

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Correct Answer is ["A","B","E"]

Explanation

Choice A reason: Selegiline, an MAOI, can cause hypertensive crisis, especially with dietary tyramine or drug interactions. Withholding the next dose prevents further escalation of the client’s severe hypertension (200/110 mm Hg), aligning with pharmacology protocols for MAOI-related crises, making this a critical nursing action.

Choice B reason: Monitoring blood pressure and pulse every 15 minutes tracks the client’s hypertensive crisis, ensuring timely detection of changes in this life-threatening condition. Frequent vital signs are essential for managing MAOI-induced hypertension, aligning with critical care standards, making this an appropriate action.

Choice C reason: Measuring hourly urinary output is relevant for fluid status but not urgent in a hypertensive crisis. Blood pressure monitoring and provider notification address the immediate danger of selegiline’s effects, making urinary output less critical and incorrect for this acute scenario’s priority actions.

Choice D reason: Discontinuing the IV infusion is unnecessary, as lactated Ringer’s with KCl is not causing the hypertension. Selegiline’s MAOI effects are the likely culprit. Stopping the IV risks fluid imbalance without addressing the crisis, making this incorrect for managing the client’s condition.

Choice E reason: Notifying the healthcare provider is essential, as the client’s severe headache and hypertension (200/110 mm Hg) suggest an MAOI-related crisis requiring urgent medical intervention. This ensures rapid management, aligning with patient safety protocols, making it a critical action for the nurse to take.

A. Confront the client's delusion as not consistent with reality. B. Schedule activity therapy twice weekly. C. Ensure the client's environment is safe. D. Lead the client by the arm to the seclusion room.

Correct Answer is C

Explanation

Choice A reason: Confronting delusions directly can increase agitation and disrupt therapeutic rapport in schizophrenia. Ensuring a safe environment addresses potential risks from delusional behavior without challenging beliefs, aligning with psychiatric nursing principles for managing psychosis, making this incorrect for the care plan.

Choice B reason: Activity therapy supports socialization but does not address the immediate safety needs posed by the client’s delusion. Ensuring a safe environment prevents harm related to grandiose beliefs, making this intervention secondary and incorrect compared to prioritizing safety in acute schizophrenia management.

Choice C reason: Ensuring a safe environment is critical for a client with schizophrenia expressing delusions, as grandiose beliefs may lead to risky behaviors. This intervention minimizes harm while supporting therapeutic engagement, aligning with safety-first psychiatric care principles, making it the most appropriate care plan inclusion.

Choice D reason: Leading the client to seclusion is overly restrictive and unwarranted based solely on a delusion, which is not inherently dangerous. Ensuring safety through environmental management is less invasive and more therapeutic, making seclusion incorrect for managing this client’s delusional statement.

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During a one-to-one session, the nurse begins to become angry with the client. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","E"]

Explanation

On admission to the mental health unit, a client diagnosed with schizophrenia tells the nurse, "I am the son of God." Based on this statement, which intervention should the nurse include in this client's plan of care?

Correct Answer is C

Explanation

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