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."

Answer and Explanation

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.

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Correct Answer is ["A","D","E"]

Explanation

The statements by the client that would require the nurse to notify the health care provider to cancel the MRI procedure are:

● “I had a pacemaker inserted a few years ago because my heart was not beating fast enough.”

● "I fell down my basement steps last year and broke my hip and had to have a hip replacement.”

● “When I was diagnosed with mitral valve prolapse, they had to replace the valve with a prosthetic valve."

These statements indicate that the client has metallic implants or devices in their body, which can be affected by the strong magnetic field of an MRI machine. This can pose a risk to the client’s safety and may interfere with the accuracy of the MRI results.

The other statements do not necessarily require the cancellation of the MRI procedure, but the nurse may need to take additional precautions or provide additional support to ensure the client’s comfort and safety during the procedure.

Here is a detailed explanation of why the other choices do not necessarily require the cancellation of the MRI procedure:

● “I have such terrible anxiety, I don’t know if I can remain still throughout the procedure.”: While anxiety can make it difficult for a client to remain still during an MRI procedure, it does not necessarily require the cancellation of the procedure. The nurse may provide additional support or medication to help the client manage their anxiety and remain still during the procedure.

● “I have diabetes mellitus type and have been taking insulin for many years.”: Having diabetes and taking insulin does not necessarily require the cancellation of an MRI procedure. The nurse may need to take additional precautions to ensure that the client’s blood sugar levels are stable during the procedure, but it does not pose a direct risk to the client’s safety or interfere with the accuracy of the MRI results.

A. The client will have stabilization and management of symptoms. B. The client will have an improvement in the quality of life. C. The client will return to prior level of functioning D. The client will be adherent to the medication regimen.

Correct Answer is B

Explanation

a.Stabilization and management of symptoms are critical goals for any client with schizophrenia. However, in psychiatric rehabilitation, the focus goes beyond merely stabilizing symptoms. The goal is often to enhance the client’s ability to function in daily life and improve their overall well-being, not just manage symptoms.

b.The primary outcome of a psychiatric rehabilitation program is to help clients improve their overall quality of life. This includes helping them develop skills for independent living, managing their symptoms effectively, enhancing social interactions, and improving their sense of purpose and well-being.

c.In cases of chronic mental health conditions like schizophrenia, it may not always be realistic or possible for clients to return to their prior level of functioning before the onset of the illness. The focus is more on helping the client achieve the best possible level of functioning within the limits of their condition, rather than returning to a specific previous state.

d.While medication adherence is crucial in the treatment of schizophrenia, it is just one component of managing the condition. Psychiatric rehabilitation is a holistic process that includes psychosocial interventions, skills training, and social support. Medication adherence supports symptom management, but it is not the primary outcome.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a client for a magnetic resonance imaging (MRI). Which statement(s) by the client would require the nurse to notify the health care provider to cancel the procedure? Select all that apply. (Select All that Apply.)

Correct Answer is ["A","D","E"]

Explanation

A client is attending a psychiatric rehabilitation program after having been in inpatient care for the treatment of relapsing schizophrenia. When creating the plan of care, which will be the primary outcome for this client?

Correct Answer is B

Explanation

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