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

Explanation

Prior to meeting with a client who is experiencing complicated grieving, the nurse should engage in self-reflection and examine their own attitudes, biases, and emotional responses related to loss and grieving. This is important because the nurse's own experiences and beliefs can influence their ability to provide empathetic and non-judgmental care to the client. By acknowledging and understanding their own feelings and reactions, the nurse can better support the client in their grieving process.

The other options are not appropriate for the following reasons:

B- Evaluating previous methods of interventions: While it is essential for the nurse to have knowledge and skills related to grief counseling and interventions, focusing solely on previous methods may not be helpful for the client's unique situation. Each individual's grieving process is different, and what worked for one client may not work for another.

C- Establishing goals for the process and presenting them to the client: While setting goals for the therapeutic relationship is important, it should be a collaborative process between the nurse and the client. The nurse should work with the client to identify their needs and goals related to the grieving process and develop a plan of care together.

D- Sharing personal information related to loss experienced by the nurse: It is not appropriate for the nurse to share their own personal experiences of loss with the client. The focus of the therapeutic relationship should be on the client's needs and experiences, not the nurse's. Sharing personal information can shift the focus away from the client and may not be helpful or therapeutic for them.

A. "You may be in more physical danger after you leave them." B. "Batterers never change, so it would be best for you to leave." C. "If you leave, maybe your partner will see that they have to change their behavior." D. "If you don't leave. your partner will think you're going to continue to endure the abuse."

Correct Answer is C

Explanation

This response is the most supportive and empowering for the client. It acknowledges the client's agency in making decisions about their own life and relationship. It also conveys hope that leaving the abusive relationship may prompt the partner to realize the need to change their behavior. It does not impose judgment or make assumptions about the outcome, but instead, it recognizes the client's strength and potential for positive change.

Option A may instill fear and discourage the client from taking action to protect themselves.

option B generalizes that all batterers never change, which may not be true for all situations and individuals.

Option D may imply a threat or ultimatum, which is not appropriate and can be disempowering for the client. The most important aspect of supporting someone in an abusive relationship is to provide a non-judgmental, understanding, and empowering environment where they can explore their options and make decisions that are best for their safety and well-being.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is meeting with a client who is experiencing complicated grieving from the death of their child to suicide. In order to establish a therapeutic nurse-client relationship, what will the nurse do prior to the meeting?

Correct Answer is A

Explanation

The nurse is working with a client at the battered women's shelter who is in a violent and abusive relationship. The client is considering a separation and asks the nurse. "What do you think about that?" Which is the best response by the nurse?

Correct Answer is C

Explanation

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