A client is noted to be pacing on the unit with their hands clenched and mumbling curses. The nurse knows that the initial approach to this client would be to:

stop the client in the hall and tell them that they must pace in the day room instead.

keep hands in pockets so as not to appear threatening.

speak softly and calmly,

offer the client a cup of coffee.

Answer and Explanation

The Correct Answer is C

a. Stop the client in the hall and tell them that they must pace in the day room instead. This can be confrontational and might escalate the situation.
b. Keep hands in pockets so as not to appear threatening. While non-threatening body language is important, the focus should be on verbal communication.
c. Speak softly and calmly. De-escalation is key in such situations. A calm and non-threatening approach is essential to build rapport and assess the situation.
d. Offer the client a cup of coffee. Stimulants like caffeine might worsen anxiety.

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Correct Answer is B

Explanation

a. question the client about choices: This might seem confrontational and does not directly help the client with stressors.
b. explore problem-solving alternatives. This is the most therapeutic purpose. Providing feedback helps the client to consider different ways to address and manage their stressors.
c. express approval or disapproval of the client's thoughts: Expressing approval or disapproval is not therapeutic and can inhibit open communication.
d. give the client good advice: Giving advice is not as effective as helping the client develop their own problem-solving skills.

A. The unit can be managed with fewer staff B. Clients are encouraged to communicate with others C. The reduced sensory input allows the client to regain control D. Clients are forced to be responsible for themselves

Correct Answer is C

Explanation

a. The unit can be managed with fewer staff. Seclusion requires close monitoring by staff.
b. Clients are encouraged to communicate with others. Seclusion is meant to be a temporary measure to prevent further harm, not necessarily to promote communication.
c. The reduced sensory input allows the client to regain control. Seclusion is a time-limited safety intervention used when a client poses a danger to themselves or others. It provides a safe space with reduced stimulation to allow the client to calm down and regain control.
d. Clients are forced to be responsible for themselves. Seclusion is not a punitive measure. The goal is to ensure safety and facilitate regaining control.

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A client is noted to be pacing on the unit with their hands clenched and mumbling curses. The nurse knows that the initial approach to this client would be to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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