During group therapy, the nurse observes that a client is pacing, agitated, and presenting with aggressive gestures. The client’s speech pattern is rapid, and affect is belligerent. Based on the observations, the nurse’s immediate priority of care is to:
Assist the staff in caring for the client in a controlled environment
Provide safety for the client and other clients on the unit
Provide the clients on the unit with a sense of comfort and safety
Offer the client a less stimulated area to calm down and gain control
The Correct Answer is B
Choice A reason:
While assisting the staff in caring for the client in a controlled environment is important, the immediate priority is to ensure safety. This choice does not directly address the immediate need to protect all clients from potential harm.
Choice B reason:
Providing safety for the client and other clients on the unit is the immediate priority. The client’s aggressive behavior poses a risk to themselves and others, and ensuring safety is the first step in managing the situation. This involves de-escalation techniques and possibly removing the client from the group setting to prevent harm.
Choice C reason:
Providing a sense of comfort and safety is important but secondary to ensuring immediate physical safety. The client’s aggressive behavior needs to be managed first to prevent any potential harm.
Choice D reason:
Offering the client a less stimulated area to calm down is a good strategy for de-escalation, but it comes after ensuring the immediate safety of all clients. The primary concern is to prevent any aggressive actions that could harm others.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Schizophrenia is rarely diagnosed in preschool-aged children. Early-onset schizophrenia can occur, but it is extremely uncommon in this age group.
Choice B reason:
While schizophrenia can develop in school-age children, it is still relatively rare. The typical age of onset is later, during adolescence or young adulthood.
Choice C reason:
Young adulthood is the most common age group for the onset of schizophrenia. Symptoms often begin to appear in late adolescence to early adulthood, typically between the ages of 16 and 30.
Choice D reason:
Schizophrenia is not typically diagnosed in older adulthood. While older adults can experience symptoms of schizophrenia, the onset of the disorder usually occurs much earlier in life.
Correct Answer is C
Explanation
Choice A reason:
Schizophrenia is rarely diagnosed in preschool-aged children. Early-onset schizophrenia can occur, but it is extremely uncommon in this age group.
Choice B reason:
While schizophrenia can develop in school-age children, it is still relatively rare. The typical age of onset is later, during adolescence or young adulthood.
Choice C reason:
Young adulthood is the most common age group for the onset of schizophrenia. Symptoms often begin to appear in late adolescence to early adulthood, typically between the ages of 16 and 30.
Choice D reason:
Schizophrenia is not typically diagnosed in older adulthood. While older adults can experience symptoms of schizophrenia, the onset of the disorder usually occurs much earlier in life.
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