A nurse enters the room of a client who becomes verbally abusive. Which of the following actions should the nurse take?
Remain a distance of 1 ft away from the client.
Speak slowly in a low, calm voice.
Forbid the client from speaking in an abusive manner.
Inform the client of consequences.
The Correct Answer is B
Choice A reason: Standing 1 ft away from a verbally abusive client is too close and may escalate the situation by invading their personal space. Maintaining a safe distance (about 3–6 ft) is recommended for safety.
Choice B reason: Speaking slowly in a low, calm voice helps de-escalate the situation by modeling calm behavior and reducing the client’s agitation. This approach promotes a safe environment and encourages de-escalation.
Choice C reason: Forbidding the client from speaking abusively may escalate their agitation, as it can be perceived as confrontational. A non-confrontational approach, like staying calm, is more effective.
Choice D reason: Informing the client of consequences may be appropriate later, but it is not the first action. De-escalation through calm communication is the priority to manage the immediate verbal abuse safely.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:Placing a client in a seclusion room is not appropriate unless they pose an immediate safety risk to themselves or others. Seclusion can increase agitation in a manic client and is not a standard room assignment for managing mania.
Choice B reason:A private room close to the nursing station allows for close monitoring of the client’s behavior, which is critical during the manic phase due to impulsivity and high energy. This setup ensures safety while providing a controlled environment without unnecessary isolation.
Choice C reason:A private room in a quiet location may reduce stimulation, which is beneficial, but it may limit the ability to closely monitor the client. Proximity to the nursing station is preferred to ensure rapid intervention if needed.
Choice D reason:A semi-private room with a roommate who has a similar diagnosis could lead to overstimulation or conflict, as two manic clients may exacerbate each other’s symptoms. A private room is more appropriate for managing mania.
Correct Answer is D
Explanation
Choice A reason:Prayer can be an effective stress management technique for some individuals, as it promotes relaxation and emotional grounding, particularly for those with spiritual beliefs, making it a helpful strategy.
Choice B reason:Journaling is an effective way to process emotions and reduce stress, especially when verbal expression is challenging. It allows clients to reflect and manage anxiety constructively.
Choice C reason:Exercise is a well-established stress management technique, as it reduces tension, releases endorphins, and promotes physical and mental well-being, making it effective for stress relief.
Choice D reason:Consuming coffee, a stimulant, can worsen anxiety by increasing heart rate and nervousness. This is the least effective technique, as it may exacerbate stress rather than alleviate it.
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