The newly licensed registered nurse has been hired at the local hospital in the geriatric-psychiatry unit. Today is the nurse's first day of orientation to this facility. What would be the nurse's priority action if a client becomes aggressive?
Reinforce boundaries when aggression is seen to maintain a safe environment
Keep the client secluded from others
Maintain a safe distance from the client
Assist other staff on the unit to take down the client safely
The Correct Answer is C
In a geriatric-psychiatry unit, the priority during an acute aggressive episode is personal and milieu safety. For a newly hired nurse, especially on their first day of orientation, maintaining a safe distance is the most immediate action to prevent injury while awaiting the intervention of the established crisis response team.
Rationale:
A. Reinforcing boundaries is a vital therapeutic intervention, but it is typically most effective during the triggering phase, before the client becomes physically aggressive. Once a client is actively aggressive, verbal boundary setting may be ignored or may even further agitate a client who is experiencing cognitive impairment or a loss of impulse control.
B. Seclusion is a highly regulated intervention that requires a specific physician's order and must follow strict legal and ethical guidelines. It is considered a restrictive intervention and is never a priority action for an individual nurse to take without a coordinated team effort and following the principle of the least restrictive environment.
C. Maintaining a safe distance, usually defined as two to three arm lengths or staying outside the strike zone, is the priority. This protects the nurse from sudden physical reach and allows for an exit path if the situation worsens. In geriatric settings, clients may be frail but can still cause significant injury through biting, scratching, or striking; physical space is the first line of defense.
D. Assisting with a take down (physical restraint) is a dangerous action for a nurse on their first day of orientation. The nurse has not yet been trained in the specific facility-approved manual hold techniques or the unit's emergency protocols. Attempting to assist in a physical restraint without proper training increases the risk of injury to both the staff and the elderly client, whose bones and skin are more vulnerable to trauma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Autism spectrum disorder is a neurodevelopmental condition characterized by impaired social interaction, restricted behaviors, communication deficits, and sensory abnormalities. Early signs include limited eye contact, reduced affective reciprocity, repetitive behaviors, and resistance to environmental or routine variability.
Rationale:
A. Thriving on changes in routine is inconsistent with autism spectrum disorder. Children typically exhibit rigidity and distress with environmental variation. Preference for sameness and predictable patterns is characteristic, making adaptability to frequent routine changes unlikely in affected individuals.
B. Avoidance of spontaneous play reflects impaired social and imaginative development. Restricted play patterns are common, with preference for repetitive or solitary activities. Lack of flexible, creative interaction indicates deficits in symbolic play and social engagement typical of autism spectrum disorder.
C. Limited facial expressions toward others indicate reduced social reciprocity. Affective blunting manifests as diminished emotional expression and poor responsiveness to social cues. This deficit interferes with interpersonal communication and is a core feature of autism spectrum disorder.
D. Rare eye contact is a hallmark early sign of autism. Eye gaze avoidance reflects impaired social attention and difficulty interpreting nonverbal cues. This behavior significantly affects bonding, communication development, and social interaction in young children.
E. Answering questions verbally suggests preserved communication ability. Language delay may occur, but verbal responsiveness generally indicates more typical social communication skills and does not strongly support suspicion of autism spectrum disorder.
Correct Answer is D
Explanation
Eating disorders, particularly Anorexia Nervosa and Bulimia Nervosa, are often associated with specific personality clusters that influence how the client interacts with the world and healthcare providers. These traits frequently include high levels of perfectionism, harm avoidance, and a significant preoccupation with social approval. Understanding these underlying characteristics allows the nurse to tailor their approach to address the client's need for control and their fear of judgment or failure.
Rationale:
A. Clients with eating disorders are rarely overtly defiant in their general personality. While they may be resistant to treatment changes regarding food and weight, their overall interpersonal style is usually characterized by compliance and a desire to avoid conflict. Defiance is more commonly associated with Oppositional Defiant Disorder or certain conduct disturbances.
B. Carelessness is the opposite of the typical presentation. These clients are usually meticulous and detail-oriented, especially concerning caloric intake, exercise regimens, and academic or professional performance. This high level of conscientiousness is a driving force behind the rigid behaviors seen in the disorder.
C. Outspokenness is uncommon, as these clients often struggle with assertiveness and the expression of negative emotions. They frequently bottle up their feelings to maintain a façade of being in control or perfect. This inability to verbally express distress often leads to the physical manifestation of their anxiety through disordered eating.
D. Being eager to please is a hallmark characteristic. Many clients have a history of being the perfect child who seeks validation through achievement and meeting the expectations of others. In a clinical setting, this may manifest as the client being exceptionally cooperative with non-food-related tasks while internally struggling with profound self-criticism and a fear of disappointing the treatment team.
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