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 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.

A. “I had a pacemaker inserted a few years ago because my heart was not beating fast enough.” B. “I have such terrible anxiety, I don't know if I can remain still throughout the procedure.” C. “I have diabetes mellitus type and have been taking insulin for many years.” D. "I fell down my basement steps last year and broke my hip and had to have a hip replacement.” E. “When I was diagnosed with mitral valve prolapse, they had to replace the valve with a prosthetic valve."

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.

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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 working in the ED of an urban hospital notifies the manager that there are several clients with mental health disorders still present in the ED that have been there over 48 hours. Which issue related to this phenomenon does the nurse discuss with the manager?

Correct Answer is C

Explanation

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

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