A novice nurse is beginning work on a behavioral health unit and states to the preceptor, "What if I encounter a client that is sexually aggressive? Which is the appropriate response by the preceptor?
"Set firm limits and boundaries for the client."
“Tell the client that you are going to report to the director of the unit.”
"Walk away and have someone else take care of the client."
"It happens frequently so just ignore it they will stop."
The Correct Answer is A
When encountering a client who is sexually aggressive, it is important for the nurse to establish firm limits and boundaries to ensure the safety and well-being of both the client and the healthcare team. This response promotes the maintenance of a therapeutic environment and helps prevent potential harm to the client, staff, and other patients.
the other choices are incorrect:
1. "Tell the client that you are going to report to the director of the unit." While it is important to report any concerning behaviors or incidents to the appropriate personnel, simply informing the client about reporting to the director may not be the most effective initial response. Prioritizing immediate actions to ensure safety and setting boundaries is crucial before involving higher-level staff.
2. "Walk away and have someone else take care of the client." Leaving the situation and passing the responsibility to someone else without addressing the issue directly is not an appropriate response. It is the nurse's responsibility to provide care and manage challenging situations within their scope of practice and training. Collaboration and support from the healthcare team may be sought, but abandoning the client is not an acceptable approach.
3. "It happens frequently, so just ignore it; they will stop." Ignoring sexually aggressive behavior is not an appropriate response. Such behavior should be taken seriously and addressed promptly to ensure the safety and well-being of everyone involved. Ignoring the behavior may enable its continuation and potentially lead to further harm or escalation of the situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1"]
Explanation
To calculate the amount of mL the nurse should administer, we can use a proportion based on the available concentration of digoxin (Lanoxin) and the prescribed dose.
The available concentration is 0.5 mg/2 mL, which means there are 0.5 mg of digoxin in 2 mL of solution.
The prescribed dose is 0.25 mg.
Now we can set up the proportion:
0.5 mg / 2 mL = 0.25 mg / x mL
Cross-multiplying, we have:
0.5 mg * x mL = 2 mL * 0.25 mg
0.5x = 0.5
Dividing both sides by 0.5, we get:
x = 0.5 / 0.5
x = 1
Therefore, the nurse should administer 1 mL of digoxin (Lanoxin) to deliver a dose of 0.25 mg.
Correct Answer is B
Explanation
A. “I can see you are anxious. Let's stop for a minute."This option interrupts the exposure process. In systematic desensitization, the goal is to continue exposure while employing relaxation techniques, so stopping would not promote the gradual reduction of anxiety.
B. “Use the deep breathing techniques we practiced yesterday."This statement encourages the client to utilize a relaxation technique (deep breathing) while facing their fear, which is the core of systematic desensitization. By practicing relaxation in the presence of the feared stimulus, the client learns to associate the stimulus with calmness rather than anxiety.
C. "What is the worst that will happen if you confront this fear?"This option uses a form of cognitive restructuring, which is more aligned with cognitive-behavioral therapy (CBT) rather than systematic desensitization. This focuses on changing thought patterns rather than gradually exposing the person to their fear while inducing relaxation.
D. “Tell me how you are feeling right now."While it is important for the client to reflect on their feelings, this option does not promote relaxation or directly help the client manage their anxiety response during exposure. It focuses more on emotional processing rather than applying the desensitization technique.
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