Which of the following interventions would a nurse use when caring for an inpatient client who expresses anger inappropriately?

Teach the client to avoid “I” statements related to the expression of feelings.

Tell the client to stop using a loud angry voice.

Use therapeutic touch to convey empathy.

Clearly explain the consequences of the behavior.

Answer and Explanation

The Correct Answer is D

Choice A Reason: Teach the client to avoid “I” statements related to the expression of feelings

Teaching a client to avoid “I” statements is not a recommended intervention. In fact, “I” statements are often encouraged in therapeutic settings because they help individuals express their feelings without blaming others. For example, saying “I feel angry when…” helps to communicate emotions constructively and can be a part of anger management strategies.

Choice B Reason: Tell the client to stop using a loud angry voice

While it might seem logical to ask a client to stop using a loud, angry voice, this approach can be counterproductive. It may escalate the situation by making the client feel unheard or invalidated. Instead, it is more effective to acknowledge the client’s feelings and then guide them towards expressing their anger in a more appropriate manner.

Choice C Reason: Use therapeutic touch to convey empathy

Therapeutic touch involves using physical touch to convey empathy and support. However, its effectiveness can vary depending on the client’s comfort with touch and cultural background. Some clients may find touch comforting, while others may find it intrusive or uncomfortable. Therefore, it is important to assess the client’s preferences and obtain consent before using therapeutic touch.

Choice D Reason: Clearly explain the consequences of the behavior

This is the correct answer. Clearly explaining the consequences of inappropriate behavior helps set boundaries and provides the client with an understanding of the impact of their actions. It is a crucial part of behavior management and helps the client learn appropriate ways to express their emotions. This approach is aligned with cognitive-behavioral strategies that focus on understanding the relationship between thoughts, feelings, and behaviors.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["A","B"]

Explanation

The correct answer is a, b.

Choice A Reason:

The statement “Organize clinical observations” is correct. One of the primary functions of the Mental Status Exam (MSE) is to systematically organize clinical observations. This includes assessing the client’s appearance, behavior, mood, and cognitive functions. By organizing these observations, healthcare providers can create a comprehensive picture of the client’s current mental state, which is crucial for diagnosis and treatment planning.

Choice B Reason:

The statement “Obtain information about the client’s medical history” is correct. The MSE often involves gathering detailed information about the client’s medical history, including past mental health issues, treatments, and any relevant medical conditions. This information helps in understanding the client’s baseline mental status and identifying any changes or abnormalities. It also aids in creating an effective treatment plan tailored to the client’s specific needs.

Choice C Reason:

The statement “Establish limit setting” is incorrect. While limit setting is an important aspect of managing certain mental health conditions, it is not a primary function of the MSE. Limit setting typically involves establishing boundaries and rules to manage behaviors, which is more relevant in therapeutic settings rather than during the assessment phase. The MSE focuses on evaluating the client’s current mental state rather than setting behavioral limits.

Choice D Reason:

The statement “Determine the client’s IQ” is incorrect. The MSE is not designed to measure a client’s intelligence quotient (IQ)4. Instead, it assesses cognitive functions such as memory, attention, and orientation. IQ tests are specialized assessments that require specific tools and are conducted separately from the MSE. The MSE provides a general overview of cognitive functioning but does not quantify intelligence.

A. Confirming boundaries by setting limits on behavior. B. Providing reality orientation. C. Providing client education in a direct manner. D. Ensuring physical need fulfillment.

Correct Answer is A

Explanation

Choice A Reason:

Confirming boundaries by setting limits on behavior.

This response is correct because it directly addresses the need to set clear boundaries with the client. In a psychiatric setting, it is crucial to establish and maintain professional boundaries to ensure a therapeutic environment. By limiting the client’s approach to the nurse’s station, the nurse is setting a clear boundary that helps manage the client’s behavior and ensures that the nurse can attend to other patients as well. This intervention helps in maintaining structure and predictability, which can be very beneficial for clients with psychiatric conditions.

Choice B Reason:

Providing reality orientation.

Providing reality orientation involves helping clients understand their surroundings and current situation, often used for clients with cognitive impairments or disorientation. While important, this intervention does not specifically address the behavior of frequently approaching the nurse’s station. Reality orientation would be more relevant in cases where the client is confused about time, place, or person.

Choice C Reason:

Providing client education in a direct manner.

Providing client education is essential, but it does not directly relate to setting behavioral limits. Education might involve explaining the reasons behind certain rules or treatments, but it does not address the immediate need to manage the client’s frequent requests. The intervention described in the question is more about behavior management than education.

Choice D Reason:

Ensuring physical need fulfillment.

Ensuring physical need fulfillment involves addressing the client’s basic needs such as food, hydration, and comfort. While this is a fundamental aspect of nursing care, it does not relate to setting behavioral limits or managing the frequency of the client’s requests. The intervention in the question is focused on managing behavior rather than fulfilling physical needs.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which of the following interventions would a nurse use when caring for an inpatient client who expresses anger inappropriately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse recognizes that a function of the Mental Status Exam is to:

Correct Answer is ["A","B"]

Explanation

A client on an acute psychiatric inpatient unit approaches the nurse’s station every 10-15 minutes with various requests. The nurse intervenes by stating, “You may approach the nurse’s station only once an hour.” Which nursing intervention has been employed?

Correct Answer is A

Explanation

The nurse notices a client wandering in the hospital hall giggling, with bizarre behavior that is annoying and frightening other clients. A priority in caring for her is to:

A 23-year-old is about to take a math test. A nursing assessment reveals mild anxiety. The nurse explains that this level of anxiety:

A nurse is caring for a client who has schizophrenia and is experiencing command auditory hallucinations. Which of the following actions should the nurse take?

A client tells the nurse, “I feel bad because my mother does not want me to return home after I leave the hospital.” Which nursing response is most therapeutic?

Group therapy is strongly encouraged, but not mandatory, in an inpatient psychiatric unit. The unit manager’s policy is that clients can make a choice about whether or not to attend group therapy. Which ethical principle does the unit manager’s policy preserve?

The nurse understands that whether or not a client experiences a crisis as a result of a stressful situation depends on:

A nurse notices that a client with paranoid schizophrenia stops in mid-sentence when talking and tilts his head to the side as if to listen. The most appropriate intervention by the nurse would be to:

During a morning group meeting, a client raises concern that they cannot sleep at night due to the noises coming from the nurse’s station. The nurse in the meeting interrupts and states, “I’ll handle this matter. Let’s move on.” The nurse is demonstrating which type of leadership style?