Exhibits

A nurse is planning care for a client who has been readmitted to an acute mental health unit. Which of the following actions should the nurse take? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

Use verbal intervention to assess the client's behavior.

Stand in front of the patient while acknowledging their behavior.

Ignore the client's escalating behavior

Approach the client with security.

Answer and Explanation

The Correct Answer is A

A. Use verbal intervention to assess the client's behavior. The first step in managing aggressive behavior is verbal de-escalation. Speaking calmly, using open-ended questions, and acknowledging the client’s emotions can help prevent further escalation and reduce agitation. Since the client has a history of aggression and medication nonadherence, early intervention is key to maintaining safety.
B. Stand in front of the patient while acknowledging their behavior. Standing directly in front of an aggressive client can be perceived as confrontational and threatening, which may provoke further aggression. Instead, the nurse should stand at an angle and maintain a safe distance while maintaining a calm, non-threatening posture.
C. Ignore the client's escalating behavior. Ignoring escalating aggression can put staff and other clients at risk. While not reinforcing negative behaviors is important in some cases, failing to intervene can lead to physical outbursts and loss of control.
D. Approach the client with security. While security may be needed if the client becomes physically violent, the first step in de-escalation should always be verbal intervention. Using security too soon can increase agitation and make the client feel threatened or cornered, escalating the situation unnecessarily.

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Correct Answer is C

Explanation

A. Cognitive reframing. Cognitive reframing is a therapeutic technique used to help individuals change negative thought patterns by looking at situations differently. It is useful for clients with anxiety or depression but is not appropriate for dementia, as it relies on rational thinking and insight, which may be impaired.
B. Thought stopping. Thought stopping is a behavioral therapy technique used to help individuals control obsessive or intrusive thoughts by interrupting them with a distraction or a verbal command. It is used in conditions such as obsessive-compulsive disorder (OCD) but is not suitable for managing dementia-related behaviors.
C. Validation therapy. Validation therapy focuses on accepting the client’s perception of reality rather than correcting or challenging it. For a client with dementia who believes a doll is their infant child, going along with their belief can reduce distress and improve emotional well-being. Instead of arguing or trying to reorient the client, validation therapy allows for a more compassionate and reassuring approach.
D. Operant conditioning. Operant conditioning is a behavior modification technique that reinforces positive behaviors through rewards or consequences. While effective for some behavioral issues, it is not appropriate for dementia care, as individuals with dementia may not retain memory of the reinforcement and may struggle to change their behaviors accordingly.

A. Reach to Recovery B. A 12-step program C. Al-Anon D. Light therapy

Correct Answer is B

Explanation

A. Reach to Recovery. This program is designed for individuals recovering from breast cancer, not for those dealing with substance use disorders. It provides education and support for people adjusting to life after a breast cancer diagnosis.
B. A 12-step program. Alcoholics Anonymous (AA) and other 12-step programs offer structured peer support and recovery strategies for individuals struggling with alcohol dependence. These programs focus on abstinence, accountability, and personal growth, making them a key resource for clients recovering from alcohol withdrawal.
C. Al-Anon. Al-Anon is a support group for family members and loved ones of individuals with alcohol use disorder. While beneficial for relatives, it is not the appropriate resource for the client who is recovering from alcohol withdrawal.
D. Light therapy. Light therapy is used to treat seasonal affective disorder (SAD) and other mood disorders, not alcohol dependence. It has no direct role in the treatment of substance use disorders.

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Exhibits A nurse is planning care for a client who has been readmitted to an acute mental health unit. Which of the following actions should the nurse take? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has dementia and insists that a doll is their infant child. Which techniques should the nurse use when interacting with the client?

Correct Answer is C

Explanation

A nurse is discharging a client who was admitted for the treatment of alcohol withdrawal. Which of the following resources should the nurse recommend to the client?

Correct Answer is B

Explanation

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Exhibits

A nurse is planning care for a client who has been readmitted to an acute mental health unit. Which of the following actions should the nurse take? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)