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

Answer and Explanation

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

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

Choice A reason:
Dependence on parents to participate in the client’s care indicates that the client is not progressing towards independence. Effective in-home mental health care aims to empower clients to manage their own health and reduce reliance on others. Therefore, this response does not demonstrate effective care.
Choice B reason:
A need for continued intensive monitoring in the home suggests that the client’s condition remains unstable and requires constant supervision. Effective care should lead to improved stability and a reduction in the need for intensive monitoring.
Choice C reason:
A decrease in admission frequency to inpatient psychiatric hospitals indicates that the client’s condition is stabilizing and that they are managing their mental health more effectively at home. This outcome demonstrates that the in-home mental health care is effective in reducing the need for hospitalization.
Choice D reason:
A need for crisis intervention services on an ongoing basis suggests that the client continues to experience frequent crises. Effective in-home mental health care should help the client develop coping strategies and support systems to manage their condition, reducing the need for frequent crisis interventions.

A. Bizarre behavior B. Somatic delusions C. Affective flattening D. Illogicality

Correct Answer is C

Explanation

Choice A reason:
Bizarre behavior is considered a positive symptom of schizophrenia. Positive symptoms are those that add abnormal experiences, such as hallucinations, delusions, and disorganized behavior. Bizarre behavior falls into this category as it represents an addition to normal behavior patterns.
Choice B reason:
Somatic delusions are also positive symptoms of schizophrenia. These delusions involve false beliefs about the body, such as believing one has a serious illness despite medical evidence to the contrary. Positive symptoms are characterized by the presence of abnormal thoughts or behaviors.
Choice C reason:
Affective flattening is a negative symptom of schizophrenia. Negative symptoms are characterized by the absence or reduction of normal functions, such as emotional expression, motivation, and social interaction. Affective flattening refers to a lack of emotional expression, where the individual shows little to no facial expressions or emotional responses.
Choice D reason:
Illogicality, or disorganized thinking, is considered a positive symptom of schizophrenia. It involves incoherent or nonsensical speech and thought patterns. Positive symptoms are those that reflect an excess or distortion of normal functions.

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

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:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing in-home mental health care and determines that the care is effective when the client demonstrates which response?

Correct Answer is C

Explanation

A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

Correct Answer is C

Explanation

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

The charge nurse is talking with another nurse who states, “I feel like my clients have no interest in their care and do not care that I am trying to help.” Which response should the charge nurse make?

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

A nurse is reviewing the DSM-5 diagnostic criteria for schizophrenia. Which of the following symptoms must be present for a client to be diagnosed with schizophrenia? (Select all that apply.)

Which client would a nurse determine to be the most likely candidate for involuntary commitment?

A nurse is talking with a client who has schizophrenia. Suddenly the client states, “I’m frightened. Do you hear that? The voices are telling me to do terrible things.” Which of the following responses by the nurse is appropriate?