A female client admitted to the mental health unit starts to shout and scream at the nurse. Which is the best approach for the nurse to take?

Stay quietly with the client.

Tell her that she is out of control.

Ignore the client's acting out, behavior.

Distract her by offering finger foods.

Answer and Explanation

The Correct Answer is A

A) Staying quietly with the client is the best approach in this situation. By remaining present and calm, the nurse can provide a sense of safety and support. This non-confrontational presence may help the client feel more secure and reduce her agitation over time.

B) Telling the client that she is out of control may escalate her frustration and feelings of being judged. This could worsen the situation rather than help it, as it does not offer any constructive feedback or support.

C) Ignoring the client's acting out behavior is not appropriate. Acknowledging her feelings and providing support is essential, even if her behavior is challenging. Ignoring her could lead to further escalation and feelings of isolation.

D) Distracting her by offering finger foods could be an effective strategy if the client is calm enough to engage in that activity. However, if she is currently shouting and screaming, she may not be receptive to distraction techniques. Addressing her emotional state first is more critical.

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Correct Answer is C

Explanation

A) Showing the client the unit can be helpful for orientation, but it may not address the client's immediate emotional state. Since the client is exhibiting paranoia and sitting quietly, they might not feel safe or ready to engage in a tour.

B) Offering medication to the client may be appropriate later, but it does not address the client's current need for safety and trust. If the client is feeling paranoid, they might be suspicious of medications offered right away.

C) Explaining the nurse's role to the client is the first and most important intervention. This helps to establish trust and reduce anxiety, as it clarifies the nurse's intentions and reassures the client that they are there to provide support. Building rapport is crucial in dealing with a client exhibiting paranoia.

D) Reading the client their rights is important but may feel overwhelming to a client who is already anxious or paranoid. It’s more effective to first build a connection and establish a sense of safety before discussing rights or other formalities.

A. Tell the client that it is important to respect others' belongings. B. Take away privileges until the behavior is extinguished. C. Nothing, her action is not harmful to others. D. Remove the client from these areas when she is agitated.

Correct Answer is D

Explanation

A) Telling the client that it is important to respect others' belongings may be a valid point, but it does not address the immediate behavior and does not provide a practical solution. Simply stating this may not help the client understand the consequences of her actions or modify her behavior.

B) Taking away privileges until the behavior is extinguished can lead to feelings of punishment and may not be effective in changing the behavior. It is essential to approach the situation with understanding rather than punitive measures.

C) Doing nothing is not an appropriate response. While the behavior may not be physically harmful, it can disrupt the community and the therapeutic environment of the facility. It is important to address the behavior proactively.

D) Removing the client from these areas when she is agitated is the most appropriate action. This intervention helps to prevent the behavior from occurring and allows the nurse to manage the client’s agitation in a constructive way. It provides an opportunity to redirect her focus and reduce her agitation, promoting a safer environment for all clients.

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A female client admitted to the mental health unit starts to shout and scream at the nurse. Which is the best approach for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. While approaching the client, which intervention should the nurse implement first?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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