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?

Role model healthy ways to express anger.

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

Assist the client to explore techniques to reduce stress.

Ask the client if he intends to harm others.

Answer and Explanation

The Correct Answer is D

The priority for the nurse is to ensure safety for the client and others in the facility. Asking the client about his or her intentions can help the nurse determine the level of risk and plan appropriate interventions, such as setting limits, providing supervision, or initiating seclusion or restraint if necessary.

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Correct Answer is C

Explanation

Selegiline is a monoamine oxidase inhibitor (MAOI), which can cause a hypertensive crisis if taken with selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine.

A. Implement continuous one-to-one observation. B. Encourage the client to participate in group therapy. C. Ask the client to sign a no-suicide contract. D. Establish a rapport to foster trust.

Correct Answer is A

Explanation

The correct answer is:

A. Implement continuous one-to-one observation.

Choice A reason:

Implementing continuous one-to-one observation is the most immediate and direct method to ensure the safety of a client who has been admitted after a suicide attempt. This involves assigning a staff member to stay with the client at all times, providing constant supervision to prevent self-harm. It is a standard safety measure in mental health facilities for clients at high risk of suicide.

Choice B reason:

While encouraging the client to participate in group therapy is a valuable part of the treatment plan, it is not the first action a nurse should take. Group therapy is beneficial for social support and developing coping strategies, but it is not an immediate safety measure for a client at risk of suicide.

Choice C reason:

Asking the client to sign a no-suicide contract can be part of the therapeutic process, but it is not the first step in acute care. These contracts involve the client agreeing not to harm themselves and to seek help if suicidal thoughts occur. However, they are not considered a substitute for active supervision and intervention.

Choice D reason:

Establishing a rapport to foster trust is crucial for effective nursing care and is an ongoing process. It helps in creating a therapeutic relationship, which is essential for the client's long-term recovery. However, it is not the immediate priority in a crisis situation where the client's safety is at risk.

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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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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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