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 C
Explanation
Boarding refers to the practice of holding patients, including those with mental health disorders, in the emergency department (ED) for extended periods due to the unavailability of appropriate psychiatric or mental health treatment facilities. This situation often occurs when there is a lack of inpatient psychiatric beds or insufficient community-based mental health resources.
When the nurse notifies the manager about clients with mental health disorders still present in the ED for over 48 hours, they are likely raising concerns about the practice of boarding. The nurse is highlighting the issue of keeping individuals with mental health disorders in an inappropriate setting for an extended duration, which can have negative implications for both the clients and the ED.
The other options are not directly related to the phenomenon of clients with mental health disorders staying in the ED for an extended period:
1. Temporary detaining orders for clients: Temporary detaining orders refer to legal provisions that allow for the involuntary detention of individuals who are at risk to themselves or others due to mental health concerns. While this may be relevant in certain situations, it does not address the broader issue of clients staying in the ED beyond 48 hours.
2. The revolving door for clients: The revolving door phenomenon refers to individuals repeatedly seeking care in the ED due to ongoing or recurrent health issues. While this may be a concern in the context of mental health, it does not specifically address the issue of clients with mental health disorders staying in the ED for over 48 hours.
3. The cost of holding clients in the ED for over 48 hours: While the cost of providing care and resources to clients staying in the ED for an extended period is a valid consideration, it does not encompass the broader issue of the appropriateness of this practice for clients with mental health disorders.
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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