A home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. The client is sitting on his front porch with a shotgun in his arms. Which of the following actions should the nurse take?
Stop the car in the client's driveway and call the authorities.
Honk the car horn to get the client's attention.
Calmly speak the client's name out of the car window.
Keep driving in a path that is going away from the client's house.
The Correct Answer is D
Choice A reason:
Stop the car in the client’s driveway and call the authorities. This statement is wrong because stopping in the driveway could escalate the situation and put the nurse in immediate danger. The nurse should avoid any actions that might provoke the client or put herself in harm’s way.
Choice B reason:
Honk the car horn to get the client’s attention. This statement is wrong because honking the horn could startle the client, potentially leading to a violent reaction. Sudden loud noises can exacerbate agitation in individuals with schizophrenia.
Choice C reason:
Calmly speak the client’s name out of the car window. This statement is wrong because engaging with the client directly while they are armed is unsafe and could provoke aggression. The nurse should avoid direct interaction until the situation is secured.
Choice D reason:
Keep driving in a path that is going away from the client’s house. This is the correct action as it ensures the nurse’s safety by distancing herself from the potentially dangerous situation. Once at a safe distance, the nurse can contact the authorities for assistance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Negative Operant Conditioning involves the removal of an unpleasant stimulus to increase the likelihood of a behavior being repeated. In this scenario, the nurse is not removing an unpleasant stimulus but is instead taking over a task to prevent conflict, which does not align with the principles of negative operant conditioning.
Choice B reason:
Positive Role Modeling is demonstrated when an individual exhibits behavior that is beneficial and can be emulated by others. By taking the tray to avoid conflict, the nurse is showing understanding and flexibility, qualities that are positive and can be modeled in a healthcare setting.
Choice C reason:
Aggressiveness is characterized by hostile or forceful behavior or attitudes. The nurse's action of taking the tray to the kitchen is not aggressive; it is a non-confrontational approach to managing the situation.
Choice D reason:
Assertiveness involves standing up for one's own rights in a direct, honest way, while also respecting the rights of others. The nurse's behavior is not assertive, as they are not addressing the client's refusal directly but are instead choosing to complete the task themselves to avoid confrontation.
Correct Answer is D
Explanation
Choice A Reason:
An adventitious crisis is not applicable here. This type of crisis is usually a result of a natural or man-made disaster, war, or major accident, which is not the case with the client's situation.
Choice B Reason:
Maturational crises are associated with life transitions or developmental stages, such as retirement or menopause. While the client is older, the crisis is not due to a normal life transition but rather an unexpected event.
Choice C Reason:
Developmental crises occur as a person moves through the stages of life. The client's crisis does not stem from a developmental issue but from an external event that has disrupted their life.
Choice D Reason:
Situational crises arise from external sources that an individual may face throughout life, such as the death of a loved one, loss of a job, or severe illness. The client's inability to cope with the sudden death of their spouse is a situational crisis.
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