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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Grandeur involves exaggerated beliefs about one’s importance or power, not misinterpretation of others’ behavior.
Choice B reason: Erotomania is a delusion in which someone falsely believes another person, often famous, is in love with them.
Choice C reason: Flight of ideas is characterized by rapid shifts from one thought to another, common in mania, not misinterpretation of laughter.
Choice D reason: Ideas of reference involve the belief that unrelated events or actions are directed toward oneself, such as assuming group laughter is ridicule.
Correct Answer is C
Explanation
Choice A reason:Clozapine is an antipsychotic used primarily for schizophrenia, not for preventing seizures. While it may lower the seizure threshold as a side effect, it is not prescribed for seizure control, making this statement incorrect.
Choice B reason:Clozapine is typically administered orally, not by intramuscular injection every 2 weeks. Long-acting injectable antipsychotics exist, but clozapine is not one of them, so this statement does not reflect correct understanding.
Choice C reason:Clozapine can cause orthostatic hypotension, leading to dizziness or fainting upon standing. Rising slowly from a lying position helps prevent this, indicating the client understands an important precaution for safe use of the medication.
Choice D reason:Ringing in the ears (tinnitus) is not a common side effect of clozapine. More common side effects include sedation, weight gain, and agranulocytosis, so this statement does not show correct understanding.
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