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 B

Explanation

The transition from a group home to an evolving consumer household typically involves promoting independence and empowering the client to become more self-sufficient. The ultimate goal is to enable the client to fulfill their daily responsibilities without the need for constant supervision or assistance.

The others are incorrect:

While meeting with a therapist on a weekly basis may be part of the client's overall mental health support, it is not the specific goal of transitioning to an evolving consumer household.

Using the increased emotional support of paid staff may be a temporary measure during the transition period, but the long-term goal is for the client to become self-reliant and less dependent on constant emotional support.

Resolving crises within a shorter time period is a desirable outcome for any mental health support system, but it does not directly relate to the specific goal of fulfilling daily responsibilities without supervision.

A. Culture plays no role in determining when a client will seek medical care. B. Nurses should focus on clients' cultures, rather than their ethnicity, when providing care. C. Nonverbal communication is important in few cultures. D. Nurses should expect clients to adapt to the care provided regardless of culture.

Correct Answer is B

Explanation

When discussing culturally competent care at a nursing staff inservice, the nurse should include information about the importance of focusing on clients’ cultures when providing care. Culture plays a significant role in determining when a client will seek medical care and how they will respond to treatment. Nonverbal communication is important in many cultures and can provide valuable information about a client’s needs and preferences. Nurses should strive to provide care that is respectful of and responsive to clients’ cultural beliefs and practices, rather than expecting clients to adapt to the care provided.

● “Culture plays no role in determining when a client will seek medical care.” This statement is incorrect because culture can play a significant role in determining when and how a client seeks medical care. Cultural beliefs and practices can influence a client’s understanding of health and illness, their attitudes towards healthcare providers, and their willingness to seek and adhere to treatment.

● “Nonverbal communication is important in few cultures.” This statement is incorrect because nonverbal communication is important in many cultures. Nonverbal cues such as body language, facial expressions, and gestures can convey important information about a client’s emotions, needs, and preferences. Understanding and responding to nonverbal communication can help nurses provide culturally competent care.

● “Nurses should expect clients to adapt to the care provided regardless of culture.” This statement is incorrect because it is not culturally competent to expect clients to adapt to the care provided without considering their cultural beliefs and practices. Nurses should strive to provide care that is respectful of and responsive to clients’ cultural beliefs and practices. This may involve adapting the care provided to meet the unique needs of each client.

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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

A client is being transferred from a group home to an evolving consumer household. The goal of this transition is for the client to eventually do what?

Correct Answer is B

Explanation

A nurse is discussing culturally competent care at a nursing staff inservice. Which of the following information should the nurse include when discussing clients' cultures?

Correct Answer is B

Explanation

The nurse is taking care of a client from a culture different from the nurse's culture. How might the nurse best provide culturally competent care?

A nurse is discussing culturally competent care at a nursing staff inservice. Which of the following information should the nurse include when discussing clients' cultures?

A nurse is assessing a client's circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

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?

A nurse is performing a mental status examination (MSE) on a client who has a new diagnosis of dementia. Which of the following components should the nurse include? (Select all that apply.)

A client is being transferred from a group home to an evolving consumer household. The goal of this transition is for the client to eventually do what?

A client has been started on antidepressants. Which interdisciplinary team member is most responsible for monitoring effectiveness and side effects of this new medication?

A client unable to work due to relapsing schizophrenia is receiving Social Security Benefits. Which benefit will this provide to the client experiencing serious mental illness?