A client is fearful and reluctant to talk after a traumatic event. Which technique will the nurse employ that is most effective when trying to engage the client in interaction?

Silence

Giving information

Focusing

Broad opening

Answer and Explanation

The Correct Answer is A

Choice A reason: Silence allows the client to process trauma at their own pace, creating a safe, non-pressurized environment. Fearful clients may need time to feel secure before speaking. This technique fosters trust, encourages emotional expression, and is particularly effective in trauma, where verbalization can be challenging due to psychological distress.

Choice B reason: Giving information provides facts but may overwhelm a fearful client, who may not be ready to process details post-trauma. This technique is less effective for engagement, as it does not address emotional barriers or encourage self-expression, which are critical for therapeutic interaction in trauma recovery.

Choice C reason: Focusing directs the conversation to specific topics, which can feel intrusive for a traumatized client. It assumes readiness to discuss, potentially increasing anxiety or withdrawal. This technique is less effective than silence, which allows the client to initiate dialogue when emotionally prepared, fostering trust.

Choice D reason: Broad opening encourages the client to choose topics but may be too vague for a fearful, traumatized client, who may feel overwhelmed by the lack of structure. Silence is more effective, as it provides space for emotional processing without pressuring the client to verbalize prematurely.

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Correct Answer is B

Explanation

Choice A reason: Insight into mental health problems varies individually and is not a defining feature of voluntary versus involuntary commitment. Both types of patients may lack insight, especially in severe mental illness, making this statement inaccurate as a legal or procedural distinction between commitment types.

Choice B reason: Involuntary commitment, under laws like a 302, restricts a client’s ability to initiate discharge due to assessed danger to self or others. Voluntary clients can request discharge, though medical advice may apply. This legal distinction defines the difference, making it the correct answer.

Choice C reason: Involuntary clients cannot universally refuse treatment, as court-ordered interventions may apply in cases of imminent danger. Both voluntary and involuntary clients have rights to refuse non-emergent treatment, but this is not the primary legal distinction between commitment types, making this option incorrect.

Choice D reason: Aggression is not a defining characteristic of voluntary commitment. Both voluntary and involuntary clients may exhibit aggression, depending on their mental health condition. The distinction lies in legal control over discharge, not behavior, making this statement inaccurate for defining commitment types.

A. It happens frequently, so just ignore it; they will stop B. Set firm limits and boundaries for the client C. Walk away and have someone else take care of the client D. Tell the client that you are going to report to the director of the unit

Correct Answer is B

Explanation

Choice A reason: Ignoring sexually aggressive behavior is unsafe and unprofessional, as it fails to address potential escalation or harm. Aggression may stem from impulsivity or mental health conditions, requiring intervention to ensure safety and maintain therapeutic boundaries, making this response inadequate and risky in a behavioral health setting.

Choice B reason: Setting firm limits and boundaries establishes clear expectations, reducing inappropriate behavior while maintaining safety. This approach addresses the client’s impulsivity or lack of control, common in mental health disorders, by reinforcing professional conduct and ensuring a therapeutic environment, making it the most effective and safe response.

Choice C reason: Walking away and delegating care avoids addressing the behavior, potentially escalating the client’s aggression or disrupting care continuity. It fails to establish boundaries, which are critical for managing behavioral issues in mental health settings, and may undermine the client’s trust in the therapeutic process, making it inappropriate.

Choice D reason: Reporting to the director without first addressing the behavior skips essential de-escalation steps. While reporting may be needed for persistent issues, immediate boundary-setting is more appropriate to manage aggression, maintain safety, and support therapeutic goals, making this response less effective as an initial action.

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A client is fearful and reluctant to talk after a traumatic event. Which technique will the nurse employ that is most effective when trying to engage the client in interaction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse recognizes that the difference between a voluntary and an involuntary commitment is what?

Correct Answer is B

Explanation

A novice nurse is beginning work on a behavioral health unit and states to the preceptor, “What if I encounter a client who is sexually aggressive?” Which is the appropriate response by the preceptor?

Correct Answer is B

Explanation

The nurse is receiving the morning report on four clients on a medical-surgical unit. Based on the information provided, which clients are at greatest risk for developing end-stage renal disease (ESRD)? (Select all that apply)

A nurse is reviewing an electronic medical record to determine if a client’s rights have been violated by another member of the healthcare team. Which finding will the nurse identify that would indicate a violation of the client’s rights?

The nurse asks the client, “What was it like for you when you first realized you had no place to go?” The client looks down and pauses for quite some time. Which action by the nurse is most therapeutic?

When is a nurse legally obligated to breach confidentiality?

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Which of the following is true regarding mental health and mental illness?

The healthcare provider prescribes haloperidol 10 mg for a client with severe psychosis, but the client refuses the medication. Which initial nursing action is appropriate?