A nurse in a mental health facility is caring for a client who is being aggressive toward other clients. Which of the following actions is the priority for the nurse to take?

Assist the client to explore techniques to reduce stress.

Role model healthy ways to express anger.

Ask the client if he intends to harm others.

Suggest the client make a list of things that make him angry.

Answer and Explanation

The Correct Answer is C

Choice A reason: While stress reduction techniques are important, they are not the immediate priority when a client is currently being aggressive.

Choice B reason: Role modeling is a long-term strategy and not appropriate for immediate intervention during an aggressive incident.

Choice C reason: This is the priority action to assess the risk of harm to others and to take necessary steps to ensure safety for all clients in the facility.

Choice D reason: Making a list is a reflective activity that may be part of a treatment plan but is not the priority action during an episode of aggression.

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Correct Answer is D

Explanation

Choice A reason: Witnessing an informed consent is a legal process that typically requires a licensed nurse or healthcare provider to ensure that the client fully understands the procedure and its risks. It is not appropriate to delegate this task to assistive personnel.

Choice B reason: Explaining the benefits of light therapy involves providing health education, which should be done by a licensed nurse or healthcare provider who has the necessary knowledge and training to ensure accurate information is conveyed.

Choice C reason: Discussing the adverse effects of medications is part of medication education and should be conducted by a licensed nurse or healthcare provider. Assistive personnel are not trained to provide this level of detailed medical information.

Choice D reason: Participating in solitary activities does not require clinical judgment and can be safely delegated to assistive personnel. This task involves engaging the client in activities that can help manage their mania and provide a therapeutic environment.

A. Identify the client's stressors. B. Talk to the client using short, simple sentences. C. Speak to the client in a loud voice. D. Request that security guards restrain the client. E. Stand directly in front of the client.

Correct Answer is ["A","B"]

Explanation

Choice A reason: Identifying the client's stressors is a crucial step in managing agitation. Understanding what triggers the client's distress can help the nurse to address the underlying issues and de-escalate the situation.

Choice B reason: Using short, simple sentences can help to communicate effectively with an agitated client. It ensures that the client can process the information without being overwhelmed, which is important for calming the situation.

Choice C reason: Speaking to the client in a loud voice is not recommended as it may escalate the situation. It's important to maintain a calm and soothing tone to avoid further agitation.

Choice D reason: Requesting that security guards restrain the client should be a last resort, only if the client poses an immediate threat to themselves or others. Less restrictive measures should be attempted first.

Choice E reason: Standing directly in front of an agitated client can be perceived as confrontational. It's better to maintain a non-threatening stance and ensure there is enough space to allow the client to feel safe.

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A nurse in a mental health facility is caring for a client who is being aggressive toward other clients. Which of the following actions is the priority for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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