A client is manipulative with staff and disruptive in the milieu. Although the client is not demonstrating behaviors that are a threat to self or others, they are refusing all medications. Which action by the nurse is most appropriate?

Inform the client that a family member will be called to see if they can help.

Prepare discharge paperwork since the client is refusing assistance.

Set clear boundaries for behavior and allow the refusal of medication.

Inform the client that without the medications, their mental status will not improve.

Answer and Explanation

The Correct Answer is C

When dealing with a client who is manipulative and disruptive but not demonstrating behaviors that are a threat to self or others, it is essential for the nurse to set clear and consistent boundaries for behavior. This helps establish a therapeutic environment and maintains the safety and well-being of both the client and others in the milieu.

Allowing the client to refuse medications is an important aspect of respecting their autonomy and right to make decisions about their own care, as long as they are not posing a risk to themselves or others. It is important to communicate with the client about the potential consequences of refusing medications and provide information about the benefits of taking prescribed medications to support their mental health.

The other options are not appropriate for the following reasons:

A- Informing the client that a family member will be called to help: Involving family members can be helpful in some situations, but it should not be used as a way to manipulate the client into compliance with treatment. Calling a family member without the client's consent may also violate the client's privacy and autonomy.

B- Preparing discharge paperwork since the client is refusing assistance: Discharging the client solely because they are refusing medication may not be appropriate or ethical if they are not posing a threat to themselves or others. Discharging the client without addressing the underlying issues may not be in the client's best interest and may not resolve the disruptive behavior.

D- Informing the client that without medications, their mental status will not improve: While it is important to provide the client with information about the benefits of medication, using this information as a threat or coercion tactic may not be therapeutic or effective. The nurse should focus on building a trusting relationship with the client and supporting them in making informed decisions about their care.

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Correct Answer is ["A","D","E"]

Explanation

The actions that are important for the nurse to take to help the client feel safe, secure, and in control of their own body are:

A. Prior to performing any intervention that requires touch, the nurse will ask permission.

This approach allows the client to feel respected and in control of their personal space. Asking for permission before any touch-related intervention acknowledges the client's autonomy and helps build trust.

D. The nurse will perform a continuous assessment of the client's anxiety level.

Continuous assessment of the client's anxiety level is important to identify any triggers or situations that may cause distress or feelings of unsafety. By monitoring the client's anxiety, the nurse can adjust care accordingly to promote a sense of security.

E. Have security present outside of the client's room to prevent anyone from coming in.

Having security present outside the client's room can provide an added layer of safety and reassurance for the client, especially if they have a history of abuse and may feel vulnerable or threatened.

It is not appropriate to:

B- Have the client perform all care independently and without assistance. The client may need assistance with certain care activities, and providing appropriate assistance can promote feelings of safety and trust.

C- Have two nurses present at all times to perform all care and procedures. While some situations may require additional staff for safety reasons, having two nurses present at all times for all care activities can be intrusive and may not respect the client's privacy and autonomy. It is essential to balance safety measures with promoting the client's sense of control and dignity.

A. An ability to feel remorse for the abuse B. Needy and possessive of the partner C. An inflated sense of self-esteem D. Encourages the partner to have a life outside the intimate relationship

Correct Answer is B

Explanation

Explanation: When completing a family assessment for a victim of intimate partner violence, the nurse may identify characteristics of the abuser that contribute to the abusive behavior. Among the options provided, "Needy and possessive of the partner" is the characteristic of the abuser. Abusers often display controlling behavior, which includes possessiveness and excessive need for control over their partners. This possessiveness may manifest as jealousy, isolation, and an attempt to limit the victim's freedom and independence.

A. An ability to feel remorse for the abuse - This characteristic is less likely to be present in an abuser. Abusers often exhibit a lack of remorse for their abusive behavior and may blame the victim or external factors for their actions.

C. An inflated sense of self-esteem - While some abusers may exhibit arrogance and an inflated sense of self-importance, it is not a defining characteristic of all abusers.

D. Encourages the partner to have a life outside the intimate relationship - Abusers typically do the opposite; they often seek to isolate their victims from their support systems and limit their social interactions outside the abusive relationship.

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A client is manipulative with staff and disruptive in the milieu. Although the client is not demonstrating behaviors that are a threat to self or others, they are refusing all medications. Which action by the nurse is most appropriate?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has been a victim of abuse since childhood. Which action(s) by the nurse is important so that the client feels safe, secure, and in control of their own body? Select all that apply. (Select All that Apply.)

Correct Answer is ["A","D","E"]

Explanation

The nurse is completing a family assessment for a victim of intimate partner violence. Which characteristic of the abuser will the nurse identify when completing the assessment?

Correct Answer is B

Explanation

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