When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?
Request backup from the staff.
Stand in the doorway.
Provide for personal space.
Encourage the client to sit down.
The Correct Answer is C
Choice A rationale:
Requesting backup from the staff may be necessary if the situation escalates further, but it is not the initial action to take. Providing for personal space and attempting to de-escalate the situation should come first.
Choice B rationale:
Standing in the doorway may not be the most effective approach because it doesn't actively address the client's agitation or attempt to de-escalate the situation.
Choice C rationale:
Providing personal space is an important initial intervention when dealing with an agitated client. This approach helps maintain safety for both the nurse and the client and can reduce the perception of threat or intrusion.
Choice D rationale:
Encouraging the client to sit down may be a helpful de-escalation technique, but it should come after providing for personal space to ensure safety and reduce tension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
This statement expresses the client's emotional state but does not provide information about immediate access to lethal means.
Choice B rationale:
This comment is the most crucial to document because it indicates the client's access to potentially lethal means, which is a significant risk factor for committing suicide.
Choice C rationale:
This statement provides information about a source of support in the client's life but does not indicate immediate access to lethal methods.
Choice D rationale:
This statement provides information about the frequency of panic attacks but does not indicate immediate access to lethal means.
Correct Answer is D
Explanation
A. Encouraging journaling may help with coping over time but does not address potential immediate safety concerns.
B. Asking about other children is not relevant to the mother’s current emotional state and does not assess risk.
C. Reassuring the mother about milestones may minimize her feelings and does not address her depression or potential risk of harm.
D. Asking the mother if she has ever thought about harming herself or her child is the priority response because it assesses for immediate risk of harm. Screening for suicidal or homicidal thoughts is essential when a parent expresses intense depression or hopelessness regarding a child’s condition.
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