The nurse is caring for several clients on the behavioral health unit. Which client will be assessed as demonstrating aggression?
A client who bursts into tears, leaves the group meeting, and sits on the bed hugging a pillow and sobbing
A client who stomps away from the nurses' station, goes into the day room, and grabs a pool cue from another client standing at the pool table
A client who tells the primary nurse "When you told me that I could not have a pass. I felt angry."
A client who tells the medication nurse, "I am not going to take that, or any other, medication."
The correct answer is B. A client who stomps away from the nurses' station, goes into the day room, and grabs a pool cue from another client standing at the pool table.
The Correct Answer is B
Aggression is a behavior characterized by hostility, anger, or violent actions toward others or objects. In the scenario described in option B, the client demonstrates aggressive behavior by stomping away from the nurses' station and grabbing a pool cue from another client. This behavior indicates hostility and potential violence towards others, which is a clear example of aggression.
Options A, C, and D do not describe aggressive behavior. Option A describes a client expressing sadness and seeking comfort by hugging a pillow and sobbing. Option C describes a client expressing anger verbally but not exhibiting aggression. Option D describes a client refusing to take medication, which may not necessarily involve aggressive behavior.
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Correct Answer is D
Explanation
In this situation, the client's safety is of utmost importance. Expressing a desire to leave the facility and harm oneself with a gun raises serious concerns about the client's safety and the risk of harm to themselves. Initiating commitment proceedings, also known as involuntary hospitalization or psychiatric hold, allows the facility to legally detain the client temporarily for their protection and evaluation by mental health professionals. This allows for a thorough assessment of the client's mental health status and the formulation of a comprehensive treatment plan to ensure their safety.
Options A, B, and C are not appropriate in this situation:
A. Calling security to detain the client may escalate the situation and could potentially lead to increased risk of harm.
B. Contacting the client's family may not be enough to ensure the client's safety, and it is essential to involve mental health professionals in evaluating the client's risk.
C. Allowing the client to leave without addressing their expressed suicidal ideation is not safe, as the client may be at high risk for self-harm or suicide. Simply referring them to community resources without further evaluation and intervention is not sufficient to address the immediate safety concern.
Correct Answer is C
Explanation
Option C demonstrates empathy and active listening. By acknowledging the client's emotions and expressing concern, the nurse creates a safe and supportive environment for the client to share their feelings. This response encourages the client to open up and express what they are going through, allowing the nurse to better understand the situation and provide appropriate care and support.
Options A and D are also empathetic but may not prompt the client to share their feelings or concerns as effectively as Option C.
Option B is not appropriate as it minimizes the client's emotions and may discourage them from expressing their feelings further.
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