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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Increase external stimuli.
Increasing external stimuli is not appropriate during a panic attack. Panic attacks are characterized by intense fear and anxiety, often accompanied by physical symptoms such as rapid heartbeat, sweating, and shortness of breath. Increasing external stimuli can exacerbate these symptoms and heighten the client’s distress. The goal during a panic attack is to reduce stimuli and create a calming environment to help the client regain control.
Choice B Reason:
Stay with the client and speak to them in a calm manner.
This is the correct response. Staying with the client and speaking to them in a calm manner provides reassurance and helps to ground them during the panic attack. The presence of a calm and supportive nurse can help reduce the client’s anxiety and provide a sense of safety. This approach aligns with therapeutic communication techniques and is effective in managing acute anxiety episodes.
Choice C Reason:
Allow the client to have their requested space.
While it is important to respect a client’s need for space, leaving them alone during a panic attack may not be the best approach. Clients experiencing panic attacks may feel overwhelmed and frightened, and the presence of a supportive nurse can help them feel safer and more secure. It is important to balance the client’s need for space with the need for support and reassurance.
Choice D Reason:
Review the updated problem list with the client.
Reviewing the updated problem list is not appropriate during a panic attack. This action requires cognitive engagement and focus, which the client may not be capable of during an acute anxiety episode. The priority during a panic attack is to help the client calm down and manage their immediate symptoms, not to discuss or review problems.
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Correct Answer is A
Explanation
Choice A Reason:
Clozapine is known to cause agranulocytosis, a potentially life-threatening condition where the white blood cell count drops significantly, leading to a higher risk of infection. Patients on clozapine must have regular blood tests to monitor their white blood cell count. Any signs of infection, such as fever, sore throat, or flu-like symptoms, should be reported to a physician immediately as they could indicate agranulocytosis.
Choice B Reason:
A decrease in hallucinations is generally a positive sign indicating that the medication is working effectively. It is not a reason to call the physician immediately. Instead, this should be discussed during regular follow-up appointments to assess the overall effectiveness of the treatment.
Choice C Reason:
While a decrease in appetite can be a side effect of clozapine, it is not typically an emergency unless it leads to significant weight loss or malnutrition. This should be monitored and discussed with the physician during regular visits. If the decrease in appetite is severe or persistent, it may warrant a call to the physician, but it is not as urgent as signs of infection.
Choice D Reason:
Insomnia can occur with clozapine use, but it is usually managed with adjustments to the medication regimen or additional treatments for sleep. While it is important to address insomnia, it does not require immediate medical attention unless it severely impacts the patient’s well-being.
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