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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse's feelings of sadness, poor sleep, and mild depression after the death of the terminally ill client indicate that the nurse is experiencing grief, which is a normal reaction to loss. However, if the nurse is finding it difficult to cope with the grief or if the grief is significantly impacting the nurse's daily life and well-being, seeking therapy is the best action.
Option B suggests seeking therapy for dysfunctional grief, which can provide the nurse with professional support and coping strategies to navigate through the grieving process. Therapeutic interventions can help the nurse process the emotions associated with the loss and provide a safe space to express and explore feelings of grief and loss.
Options A, C, and D may be helpful in certain situations, but they may not directly address the nurse's unresolved grief:
A. Taking a leave of absence to pursue healing can be considered if the nurse's grief is severely impacting their ability to function and provide safe patient care. However, it may not be necessary for everyone, and seeking therapy would be a more specific and targeted approach to address the grief.
C. Using stress reduction strategies can be beneficial for managing stress and promoting overall well-being, but it may not directly address the specific grief experienced by the nurse after the client's death.
D. Seeking an informal forum for discussing death can be helpful in processing feelings and emotions related to death and loss. However, it may not provide the level of support and guidance that therapy can offer in resolving grief.
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.
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