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 D
Explanation
Choice A reason: Being preoccupied with repetitive activities such as folding clothes can sometimes occur in individuals with obsessive-compulsive disorder or autism spectrum disorders, but it is not a defining feature of schizophrenia.
Choice B reason: Elation and unusual talkativeness are hallmark features of mania in bipolar disorder, not schizophrenia.
Choice C reason: Recurrent thoughts of past trauma are more characteristic of post-traumatic stress disorder (PTSD), not schizophrenia.
Choice D reason: Creating words that have no meaning, also called neologisms, is a common positive symptom of schizophrenia and reflects disorganized thought processes.
Correct Answer is B
Explanation
Choice A reason: Delayed menarche at age 13 is within normal developmental variation. Although it may cause concern for the adolescent, it is not an immediate priority unless accompanied by other signs of delayed puberty.
Choice B reason: Expressing social isolation and rejection is a priority because it may indicate depression or risk for self-harm. Adolescents who feel excluded and disliked are more vulnerable to mental health crises.
Choice C reason: Perceiving parents as overprotective is common in adolescence as teenagers seek independence. This is not typically a clinical concern.
Choice D reason: Concerns about acne and appearance are common during adolescence and usually reflect normal developmental self-consciousness rather than a safety issue.
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