A client admitted to the mental health unit starts to shout and scream at the nurse. Which approach is best for the nurse to take?

Tell the client they are out of control.

Stay quietly with the client.

Distract the client by offering finger foods.

Ignore the client's acting out behavior.

Answer and Explanation

The Correct Answer is B

Choice A rationale: Telling the client they are out of control may escalate the situation and provoke further aggression. It is not a therapeutic or de-escalation technique.

Choice B rationale: Staying quietly with the client is a calm and non-confrontational approach. It allows the client to express emotions while conveying a supportive presence.

Choice C rationale: Distracting the client by offering finger foods may not be appropriate during a shouting episode, as it may be perceived as dismissive of the client's feelings or concerns.

Choice D rationale: Ignoring the client's acting-out behavior is not the best option. The nurse should acknowledge the client's emotions and provide support rather than ignoring the distress.

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Correct Answer is C

Explanation

Choice A rationale: Initiating an exercise program may be a helpful intervention, but the primary goal for this client following a drug overdose and romantic relationship issues is to return to the previous level of functioning.

Choice B rationale: Identifying positive personal traits is a positive goal but may not be the most immediate priority for this client.

Choice C rationale: Returning to the previous level of functioning is the primary goal for hospitalization. This goal involves restoring the client's ability to manage daily life and cope with stressors.

Choice D rationale: Describing what is needed in a romantic relationship is important, but the immediate focus is on the client's overall functioning and safety.

A. Document the finding on the Abnormal Involuntary Movement Scale. B. Assist the client in recognizing her manifestations of anxiety. C. Prepare to initiate seizure precautions for the client's safety. D. Advise the client that she has developed tolerance to the medication

Correct Answer is A

Explanation

Choice A rationale: Documenting the finding on the Abnormal Involuntary Movement Scale (AIMS) is appropriate. The AIMS is a standardized tool used to assess and document abnormal movements associated with antipsychotic medications, such as tardive dyskinesia.

Choice B rationale: Assisting the client in recognizing her manifestations of anxiety is unrelated to the observed foot tapping and does not address the potential side effects of antipsychotic medication.

Choice C rationale: Preparing to initiate seizure precautions for the client's safety is not indicated based on the observed foot tapping. Seizure precautions are not typically associated with antipsychotic medication side effects.

Choice D rationale: Advising the client that she has developed tolerance to the medication is speculative and not supported by the information provided. The observed foot tapping may be indicative of extrapyramidal side effects rather than tolerance.

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A client admitted to the mental health unit starts to shout and scream at the nurse. Which approach is best for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A college student is admitted to the mental health unit following a drug overdose. The student tells the nurse about the overdose following the end of a romantic relationship. Which is the primary goal for hospitalization that should be included in this client's plan of care?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

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