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 D
Explanation
Assessing the carotid pulse simultaneously on both sides of the neck can potentially lead to excessive pressure on the carotid arteries, which supply blood to the brain. This pressure can compromise blood flow to the brain and result in adverse effects, such as decreased blood supply and oxygenation to the brain tissues.
In clinical practice, it is generally recommended to assess the carotid pulse unilaterally, meaning one side at a time, to ensure adequate blood flow to the brain is maintained during the assessment. This allows for a proper evaluation of the pulse without interfering with the circulatory system.
The other choice are incorrect:
Femoral: Assessing the femoral pulse bilaterally at the same time is generally considered safe. The femoral artery is located in the groin area and provides blood supply to the lower
extremities. Bilateral assessment allows for comparison of pulses and evaluation of circulation in both legs.
Popliteal: The popliteal pulse is located behind the knee. Similar to the femoral pulse, assessing the popliteal pulse bilaterally at the same time is typically safe. It allows for comparison between both legs and evaluation of lower limb circulation.
Brachial: The brachial pulse is located in the upper arm and is commonly used for blood pressure measurement in clinical settings. Assessing the brachial pulse bilaterally at the same time is generally considered safe and is routinely done during blood pressure assessment.
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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