A nurse in a mental health facility is caring for a client who becomes upset and breaks a chair when a visitor does not arrive. The client remains agitated following initial verbal attempts to calm him down. Which of the following interventions should the nurse implement first?

Plan with the client for how he can better handle frustration.

Place the client in a monitored seclusion room until he is calm.

Offer the client an antianxiety medication.

Restrain the client to prevent injury to himself or others.

Answer and Explanation

The Correct Answer is C

A. Planning with the client for how he can better handle frustration (option A) is a valuable intervention, but it may not be immediately effective in the midst of heightened agitation. It is better suited for a calmer, more reflective time.

B. Placing the client in a monitored seclusion room until he is calm (option B) is an option for managing extreme agitation, but it should be used cautiously and as a last resort. Offering medication and attempting verbal de-escalation are generally preferable initial steps.

C. Offer the client an antianxiety medication.
When dealing with a client who is agitated and potentially escalating to a more volatile state, offering an antianxiety medication can be a helpful and immediate intervention to manage acute distress. It can aid in calming the client down and create an environment where other therapeutic interventions can be more effectively implemented.

D. Restraining the client to prevent injury to himself or others (option D) is a highly invasive intervention and should only be considered when there is an imminent risk of harm to the client or others. It is generally not the first choice in managing agitation due to its potential negative impact on the therapeutic relationship and the client's well-being.

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Correct Answer is C

Explanation

A. Identification: Identification involves taking on the characteristics of another person, group, or entity. The client's response is not an example of identification.

B. Relation-formation: This term is not a recognized defense mechanism in the context of classical psychoanalytic theory. It seems to be a combination of two concepts but doesn't fit the context of the client's statement.

C. Projection
Projection is a defense mechanism where an individual attributes their own unacceptable thoughts, feelings, or impulses to another person. In this scenario, the client is projecting their own feelings of anger and a desire to have a drink onto the nurse and others, suggesting that the staff is angry at them and wants to go out for a drink.

D. Compensation: Compensation involves making up for a perceived weakness by emphasizing a strength in another area. The client's statement do

A. Check the bruises at the next visit to the client's home. B. Follow the agency's guidelines for reporting suspected abuse. C. Institute more frequent visits to the client's home. D. Arrange referral for family therapy to deal with home stressors.

Correct Answer is B

Explanation

A. Checking the bruises at the next visit may delay necessary intervention. If abuse is suspected, immediate action, such as reporting, is essential to protect the client.

B. Following the agency's guidelines for reporting suspected abuse is the priority when abuse is suspected. Reporting abuse to the appropriate authorities, such as adult protective services or law enforcement, is crucial to ensure the safety and well-being of the older adult.

C. Instituting more frequent visits to the client's home might be part of a safety plan, but it should not be the first action. Reporting suspected abuse is the priority to involve the appropriate authorities.

D. Arranging a referral for family therapy is not the first step in suspected elder abuse. Safety and protection of the older adult take precedence. Once the immediate safety concerns are addressed, additional interventions, such as family therapy, may be considered.

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A nurse in a mental health facility is caring for a client who becomes upset and breaks a chair when a visitor does not arrive. The client remains agitated following initial verbal attempts to calm him down. Which of the following interventions should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the court-ordered admission of a client to a substance-abuse program. The client states, "You are all angry at me and wish you could go out and have a drink." The client's response is an example of which of the following defense mechanisms?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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