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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Explanation: When dealing with a client who has been physically aggressive and is in distress, the best approach for the nurse is to use brief statements and questions to obtain essential information. This approach helps to keep the communication clear, focused, and non-threatening. The nurse should maintain a calm and assertive demeanor while avoiding lengthy discussions that may escalate the client's agitation.

Options not appropriate in this situation:

B. Providing close contact to increase the client's sense of safety may not be safe for the nurse or the client, especially when dealing with someone who has been physically aggressive. It is essential to maintain a safe distance and ensure the safety of everyone involved.

C. Having a sense of humor to show a lack of fear can be misinterpreted by the client and may not be appropriate or therapeutic in this context. The focus should be on establishing a professional and respectful rapport with the client, prioritizing their needs and safety.

Option D may not be the best approach because open-ended questions could lead to lengthy responses, which may not be suitable for a client who is in distress and potentially aggressive. The nurse should aim for concise and clear communication to ensure safety and facilitate a psychiatric assessment efficiently.

A. Autonomy B. Justice C. Beneficence D. Veracity

Correct Answer is C

Explanation

The correct answer is c. Beneficence.

Choice A: Autonomy

Autonomy refers to the right of individuals to make decisions about their own lives and bodies. In the context of nursing, it means respecting a patient’s right to make their own healthcare decisions. However, in the case of seclusion due to loud and intrusive behavior, the primary concern is not about the patient’s decision-making capacity but rather the safety and well-being of the patient and others on the unit.

Choice B: Justice

Justice is the ethical principle that emphasizes fairness and equality. It involves ensuring that patients are treated fairly and that resources are distributed equitably. While justice is important in healthcare, it does not directly address the appropriateness of seclusion in response to disruptive behavior.

Choice C: Beneficence

Beneficence is the ethical principle that focuses on doing good and acting in the best interest of the patient. It involves taking actions that promote the well-being of patients and prevent harm. In the context of seclusion, beneficence guides the nurse to consider whether secluding the patient will prevent harm to the patient and others, thereby promoting overall safety and well-being.

Choice D: Veracity

Veracity refers to the principle of truth-telling and honesty. It involves providing accurate and truthful information to patients. While veracity is crucial in building trust between healthcare providers and patients, it does not directly relate to the decision of whether to use seclusion for managing disruptive behavior.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A client who has been physically aggressive arrives at the emergency department for a psychiatric assessment. Which approach would be best for the nurse to use?

Correct Answer is A

Explanation

A nurse is questioning another nurse about whether it is ethical to seclude a client because of loud and intrusive behavior on the unit. Which is the ethical principle that will best guide the nurse's decision on the appropriate use of seclusion?

Correct Answer is C

Explanation

The nurse is caring for several clients on the behavioral health unit. Which client will be assessed as demonstrating aggression?

The school nurse is seeing a 7-year-old child in the clinic and is concerned with behaviors and physical indications that indicate the child is being sexually abused. Which is the priority action by the nurse?

An alert, oriented older adult client has been financially and emotionally abused by their adult children for the past several years but has not reported the abuse to anyone. Which reason does the nurse identify is most likely why the client has not reported the abuse?

A nurse cared for a terminally ill client for over a month and developed a therapeutic nurse-client relationship. After the client's death, feelings of sadness. sleeping poorly, and feeling mildly depressed were experienced by the nurse. Which is the best action to improve the resolution of grief?

A client is informed by the nurse that they must take their medication, and the client kicks the nurse and runs to their room. Which action by the nurse demonstrates that the nurse falsely imprisons the client?

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?

A client is observed pacing the hall with clenched fists and swearing at others. The nurse intervenes immediately in a calm manner to prevent the client from moving to which phase of the aggression cycle?

The nurse approaches a client who looks very sad and is sitting alone crying. Which is the best response by the nurse in this situation?