A client with depression is admitted for voluntary treatment. While in the hospital, the client makes several comments about leaving the facility and kiling themselves with their gun. Which is the most appropriate action by the nurse when the client requests to leave against medical advice?

Call security and ask them to detain the client from leaving.

Contact the client's family to request they convince the client to stay.

Allow the client to leave, with a referral to community resources for follow-up care.

Contact the psychiatrist for initiation of commitment proceedings.

Answer and Explanation

The Correct Answer is D

In this situation, the client's safety is of utmost importance. Expressing a desire to leave the facility and harm oneself with a gun raises serious concerns about the client's safety and the risk of harm to themselves. Initiating commitment proceedings, also known as involuntary hospitalization or psychiatric hold, allows the facility to legally detain the client temporarily for their protection and evaluation by mental health professionals. This allows for a thorough assessment of the client's mental health status and the formulation of a comprehensive treatment plan to ensure their safety.

Options A, B, and C are not appropriate in this situation:

A. Calling security to detain the client may escalate the situation and could potentially lead to increased risk of harm.

B. Contacting the client's family may not be enough to ensure the client's safety, and it is essential to involve mental health professionals in evaluating the client's risk.

C. Allowing the client to leave without addressing their expressed suicidal ideation is not safe, as the client may be at high risk for self-harm or suicide. Simply referring them to community resources without further evaluation and intervention is not sufficient to address the immediate safety concern.

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Correct Answer is B

Explanation

Using active listening techniques and providing a supportive and non-judgmental environment can promote the client's ability to express their feelings. Many clients facing end-stage illnesses, such as alcoholic cirrhosis, may experience a range of emotions and find it difficult to talk about their illness or impending loss of life. By being present, attentive, and using silence when appropriate, the nurse allows the client the space and time they need to process their thoughts and emotions and feel comfortable expressing their feelings when they are ready.

Incorrect:

Option A may come across as confrontational and judgmental, which can hinder the client's willingness to share their feelings.

Option C may be appropriate if the client requests spiritual or religious support, but it should not be assumed as the primary intervention for promoting emotional expression.

Option D can be seen as dismissive and insensitive to the client's emotional needs, and it may not be helpful in encouraging the client to open up about their feelings.

A. "We will have to talk about this later." B. "what happened that got you so upset?" C. "You really scared me. I'm glad you are okay." D. "Your behavior is unacceptable and will not be tolerated

Correct Answer is B

Explanation

When a client has an angry outburst and then quickly appears calmer and receptive to input from the nurse, it is important for the nurse to address the underlying cause of the outburst and explore the client's feelings and emotions. By asking, "What happened that got you so upset?", the nurse is inviting the client to express their feelings and share what triggered their anger. This can help the nurse understand the client's perspective, provide appropriate support, and potentially de-escalate any remaining tension or frustration.

The other options are inappropriate because:

A- "We will have to talk about this later." This response may make the client feel dismissed or that their feelings are not being heard or understood.

C- "You really scared me. I'm glad you are okay." While this response acknowledges the client's emotional state, it centers the focus on the nurse's feelings rather than exploring the client's perspective or emotions.

D- "Your behavior is unacceptable and will not be tolerated." This response is confrontational and judgmental, which can escalate the situation and potentially trigger further defensive reactions from the client.

Overall, a non-judgmental and empathetic approach that focuses on understanding the client's feelings and experiences is more likely to foster open communication and provide the client with a safe space to express themselves.

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A client with depression is admitted for voluntary treatment. While in the hospital, the client makes several comments about leaving the facility and kiling themselves with their gun. Which is the most appropriate action by the nurse when the client requests to leave against medical advice?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with end-stage alcoholic cirrhosis of the liver is hesitant to talk about the illness and the impending loss of life from their alcohol use disorder. Which action by the nurse can promote the client's ability to express their feelings?

Correct Answer is B

Explanation

After an Angry outburst, a client quickly appears calmer and receptive to input from the nurse. Which is the most helpful response to the client at this time?

Correct Answer is B

Explanation

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?

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?

The nurse is completing a family assessment for a victim of intimate partner violence. Which characteristic of the abuser will the nurse identify when completing the assessment?

A nurse is working with a client who has frequent angry outbursts which is disrupting life at home. Which statement by the nurse is most helpful when working with this client?

An angry client has just thrown a chair across the room and is racing to pick up another chair to throw. Which is the most appropriate action by the nurse?

A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed ½ cup of juice, 3 oz gelatin. 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?

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 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?