The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Alert the assigned staff to closely monitor client and intervene as needed to reduce risk of selfmutilation.

Provide the client time alone in the client's room to reduce external stimulation and promote relaxation.

Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed.

Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm.

Answer and Explanation

The Correct Answer is A

A. The client's increased body tension and pacing indicate escalating distress and potential risk for self-harm. Alerting staff to closely monitor the client and intervene as needed is crucial to ensure the client's safety.
B. Providing time alone in the client's room may be appropriate in some situations but may not address the immediate risk of self-mutilation if the client is experiencing escalating distress. C. Giving firm, consistent expectations about self-mutilating behaviors is important for establishing boundaries, but it may not be sufficient to address the immediate risk of self-harm without additional monitoring and intervention.
D. Completing a thorough room search is important for safety but may not address the immediate risk of self-harm if the client is already exhibiting signs of distress and pacing in the hallway.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

"If the client decides not to report their friend to the police, it is still a good idea to collect the evidence." Understanding: This statement acknowledges the importance of preserving evidence even if the client chooses not to involve the police. Collecting evidence can be crucial for future legal proceedings or for the client's own decision-making process.
-"Even if the client will not call the police, the nurse should advise the police of what has happened." No understanding: This statement suggests that the nurse should bypass the client's autonomy and directly involve the police without the client's consent. It fails to recognize the importance of respecting the client's autonomy and confidentiality.
-"The client has to consent in order for me to document his injuries in the chart." Understanding: This statement demonstrates an understanding of the importance of obtaining the client's consent before documenting any information related to their care, including injuries, in their medical chart.
-"Consent is not required to collect evidence from a person who has been sexually assaulted." No understanding: This statement is incorrect. Consent is always required, even when collecting evidence from a person who has been sexually assaulted. Failing to obtain consent could violate the individual's rights and lead to legal and ethical repercussions.
-"The sexual assault exam should only be done by a Sexual Assault Nurse Examiner, the Emergency Room attending physician, or other expert." Understanding: This statement correctly
Prepared by Brandel
identifies that sexual assault exams should ideally be performed by trained professionals, such as Sexual Assault Nurse Examiners or emergency room physicians with expertise in forensic examinations. These professionals are better equipped to handle the sensitive nature of such exams and collect evidence effectively.

A. Determine the type and size of the locks. B. Plan a list of activities to be carried out daily. C. Discuss checking the time frequently. D. Ask the client why the locks are checked so frequently.

Correct Answer is B

Explanation

- Choice A Rationale: Determining the type and size of the locks does not address the client's anxiety or the behavior that is impacting their daily functioning. This action might inadvertently reinforce the client's focus on the locks rather than addressing the underlying issue.
- Choice B Rationale: Planning a list of activities to be carried out daily can help the client establish a routine, which may reduce anxiety and the need for repetitive checking. This approach encourages the client to focus on the day's tasks and can provide a sense of control and accomplishment.
- Choice C Rationale: Discussing checking the time frequently does not directly address the client's repetitive behavior or the associated anxiety. While time management may be part of a broader treatment plan, it is not the most immediate action the nurse should take.
- Choice D Rationale: Ask the client why the locks are checked so frequently is not therapeutic and may put the client on the defensive. Clients with obsessive-compulsive behaviors often cannot explain why they perform rituals, as the behavior is driven by anxiety rather than logic. Asking "why" may increase frustration without helping to address the behavior.

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The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse caring for this client is working with a new nurse. The nurse teaches the novice nurse about the legal and ethical issues surrounding the client's case. Mark whether the statement by the student nurse indicates understanding or no understanding.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

A client engages in repeated checks of door and window locks and behavior that prevents the client from arriving on time and interfering with the ability to function effectively. Which action should the nurse take?

Correct Answer is B

Explanation

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Which intervention(s) should the nurse include in the plan of care for an adolescent client who is depressed? Select all that apply.

A client requests permission for the spouse to remain in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. Which action should the nurse take?

A client who has agoraphobia is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?