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 in the emergency department (ED) for extended periods, often beyond the recommended timeframe, due to a lack of available mental health treatment options or appropriate placement. In this scenario, the nurse is notifying the manager about the presence of clients with mental health disorders who have been in the ED for more than 48 hours. This situation suggests that the hospital is likely practicing boarding for these clients.
Boarding of mental health patients in the ED can have significant negative consequences. It can contribute to overcrowding in the ED, leading to delays in care for other patients. It can also compromise the quality of care and exacerbate the distress and discomfort experienced by individuals with mental health disorders. Additionally, it is not an optimal environment for mental health treatment and recovery.
By discussing the issue of boarding with the manager, the nurse is addressing the need for timely and appropriate placement for clients with mental health disorders. This conversation may involve exploring solutions such as improving access to mental health services, establishing dedicated mental health units or crisis stabilization centers, and collaborating with community resources to ensure a smooth transition of care for these clients.
The other options mentioned are not directly related to the issue of clients with mental health disorders being present in the ED for over 48 hours:
● Temporary detaining orders for clients: This refers to legal mechanisms that allow for the temporary detention of individuals with mental health disorders who may pose a risk to themselves or others. While it may be related to the care of these clients, it does not address the issue of prolonged stays in the ED.
● The revolving door for clients: This concept refers to the frequent readmission or return of clients to the ED or hospital due to ongoing mental health issues. While it is a concern in mental health care, it does not specifically pertain to the issue of clients remaining in the ED for an extended period.
● The cost of holding clients in the ED for over 48 hours: While the cost implications of extended stays in the ED are relevant, the primary concern in this scenario is the quality of care, appropriate placement, and the impact on both the clients and the ED's functioning.
Correct Answer is C
Explanation
Social Security benefits can provide financial support to individuals who are unable to work due to a serious mental illness such as relapsing schizophrenia. This financial support can help the client maintain some level of independence by providing them with a source of income. However, it is important to note that the amount of benefits received may not be sufficient to cover all of the client’s expenses, including the cost of medication and other bills. Social Security benefits do not guarantee access to psychiatric services or dictate the type of treatment that a client can receive.
The other choices are incorrect for the following reasons:
● “The client will have the ability to obtain psychiatric service regardless of setting.” This statement is incorrect because receiving Social Security benefits does not guarantee access to psychiatric services. Access to care can depend on a variety of factors, including the availability of services in the client’s area and their ability to pay for care.
● “The client will be able to pay all of their bills as well as purchase medication.” This statement is incorrect because the amount of Social Security benefits received may not be sufficient to cover all of the client’s expenses. The cost of living and healthcare can vary widely, and the amount of benefits received may not be enough to cover all of the client’s bills and medication costs.
● “The client will have the option to only obtain inpatient treatment.” This statement is incorrect because receiving Social Security benefits does not dictate the type of treatment that a client can receive. The appropriate treatment for a client with relapsing schizophrenia will depend on their individual needs and circumstances. Inpatient treatment may be appropriate in some cases, but other forms of treatment, such as outpatient therapy or medication management, may also be effective.
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