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.

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Correct Answer is C

Explanation

Choice A reason:
Projection involves attributing one’s own unacceptable thoughts or feelings to others. This is not the correct answer because the man’s behavior of punching walls and yelling at his significant other is an outward expression of his own frustration, rather than projecting his feelings onto someone else. Projection would involve accusing others of having the feelings or thoughts that he himself is experiencing.
Choice B reason:
Denial is a defense mechanism where an individual refuses to accept reality or facts, blocking external events from awareness. This is not the correct answer because the man’s actions indicate that he is reacting to his frustration rather than denying its existence. Denial would involve ignoring or refusing to acknowledge the feelings or situation that is causing distress.
Choice C reason:
Displacement is the redirection of emotions or impulses from a threatening target to a safer one. This is the correct answer because the man redirects his anger from his supervisor, who is the source of his frustration, to a less threatening target, which is his significant other and the walls at home. Displacement allows the individual to express their emotions in a way that feels safer or more acceptable.
Choice D reason:
Passive-aggression involves expressing negative feelings indirectly rather than openly addressing them. This is not the correct answer because the man’s behavior is direct and aggressive, rather than passive. Passive-aggressive actions might include sulking, procrastination, or subtle resistance, none of which are evident in the described scenario.

A. The document tells what treatment is to be omitted or provided if the client is unable to make the decision. B. A client is required to sign the “living will” document with an attorney present. C. An attorney draws up the papers to be given to the client and his or her family. D. The client’s physician must act as a witness when the client signs the document.

Correct Answer is A

Explanation

The correct answer is A.
Choice A reason:
An advance care directive, or “living will,” is a legal document that specifies what medical treatments the client wishes to receive or omit if they become unable to make decisions for themselves. This document guides healthcare providers and family members in making decisions that align with the client’s preferences.
Choice B reason:
A client is not required to sign the “living will” document with an attorney present. While it is advisable to consult with an attorney when creating legal documents, it is not a requirement for the validity of an advance care directive.
Choice C reason:
An attorney may assist in drafting the advance care directive, but it is not necessary for the attorney to draw up the papers. The client can create the document with the help of healthcare providers or legal advisors.
Choice D reason:
The client’s physician does not need to act as a witness when the client signs the document. Typically, witnesses are required to ensure the document is signed voluntarily and without coercion, but they do not have to be the client’s physician.

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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

After being scolded by his supervisor at work, a man comes home and punches several holes in his walls and yells at his significant other. Which of the following defense mechanisms does this scenario depict?

Correct Answer is C

Explanation

A nurse is explaining advance care directives, or “living wills,” to a client and the client’s spouse. Which detail would the nurse include in the description of an advance care directive?

Correct Answer is A

Explanation

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

When engaged in therapeutic communication with a client who has been diagnosed with a mental disorder, which is the most important principle for a nurse to keep in mind?

A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?

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.)

A nurse is developing a plan of care integrating Maslow’s hierarchy of needs. Which area would the nurse identify as the priority?

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 nurse is caring for a client who has bipolar disorder. The client says to the nurse, “Give me your pen to cut the pain out of my chest.” The nurse should identify that the client is at risk for which of the following?

A nurse manager is discussing suicide with nursing staff. Which of the following should the manager identify as risk factors for suicide? (Select all that apply)