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?

Recovery

Crisis

Escalation

Triggering

Answer and Explanation

The Correct Answer is C

The client's observed behavior of pacing the hall with clenched fists and swearing at others indicates that they are in the escalation phase of the aggression cycle. During this phase, the individual's anger and agitation increase, and their behavior becomes more intense and aggressive. If not addressed promptly and effectively, the situation can escalate further and potentially lead to a crisis or violent outburst.

By intervening immediately and calmly, the nurse aims to prevent the situation from escalating further and moving into the crisis phase, where the risk of harm to the client and others is highest. Effective de-escalation techniques, such as using a calm and non-threatening demeanor, active listening, and providing clear and respectful communication, can help the client regain control and reduce their agitation.

Option A - Recovery: The recovery phase comes after the aggressive incident, during which the individual may feel remorse or embarrassment about their behavior.

Option B - Crisis: The crisis phase is the point where the individual's anger and agitation reach a peak, and there is a high risk of violence or harmful actions.

Option D - Triggering: The triggering phase is the initial phase of the aggression cycle, where the individual's anger begins to build, and certain triggers may set off their aggressive behavior.

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

Every individual has the right to refuse medical treatment, including medications, as long as they are competent to make that decision. It is essential to respect the client's autonomy and right to make decisions about their own health care. When a client refuses medication, the nurse should document the refusal, inform the healthcare provider, and explore the reasons behind the refusal if possible.

The other options are not appropriate for the following reasons:

B- Obtaining a discharge order for nonadherence: While it is essential to address nonadherence to medication, discharging the client solely for refusing the medication may not be the best course of action. Instead, the nurse should work collaboratively with the healthcare team to address the client's concerns and explore alternative treatment options.

C- Restraining the client and giving the medication intramuscularly: Restraints should only be used as a last resort when a client presents an imminent danger to themselves or others, and it must be done in accordance with facility policies and legal regulations. Using restraints to administer medication against a client's will is a violation of their rights and is not an appropriate response to medication refusal.

D-Informing the client that refusing the medication means not getting any better: This response may be seen as coercive and manipulative. It is not ethical to use fear or guilt to persuade a client to take medication against their will. Instead, the nurse should provide information about the potential benefits and risks of the medication and address the client's concerns or fears about the treatment. Ultimately, the decision to take the medication should be left to the client after they have been fully informed about their options.

A. Blood pressure B. Cyanosis C. Nausea D. Petechiae

Correct Answer is C

Explanation

Objective data:

Blood pressure (can be measured by the nurse)

Cyanosis (can be observed by the nurse)

Petechiae (can be observed by the nurse)

So, the subjective data in this list is "Nausea." This is information that the client shares with the nurse about their symptoms or feelings.

The objective data includes A-"Blood pressure," B-"Cyanosis," and D-"Petechiae," which are findings that the nurse can measure or observe during the physical examination.

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 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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?

Correct Answer is C

Explanation

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?

The client with terminal lung cancer says to the nurse. "I really want to see my first grandchild born before I die. Is that too much to ask?" Which stage of grieving will the nurse document the client is experiencing?

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 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.)

A nurse auscultates a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take

A nurse is assessing several clients who have experienced loss. Which client will the nurse identify as experiencing complicated grieving? Select all that apply. (Select All that Apply.)

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?

A young client tells the nurse that the client's spouse died 3 months ago, and the client is feeling alone and vulnerable. Which statement indicates that the client's coping skills are adequate?