A nurse in a mental health facility is caring for a client who is upset about the loss of privileges due to repetitive negative behavior. Which of the following statements by the nurse demonstrates the effective use of assertive communication?

"Why did you make the choice to behave negatively?”

"You need to calm down and forgive me before discussing this matter any further.”

"You were made aware of the consequences of negative behavior so you better go to your room.”

"I understand that you are angry. However, I followed the appropriate protocol.”

Answer and Explanation

The Correct Answer is D

Choice A rationale:

This response uses a confrontational tone and places blame on the client for their behavior, which is not an example of assertive communication. It can potentially escalate the situation and hinder effective communication.

Choice B rationale:

This statement is authoritarian in nature, using phrases like "you need to" and "forgive me," which can further upset the client and create a power struggle. It lacks empathy and understanding, making it ineffective for assertive communication.

Choice C rationale:

While this response acknowledges the consequences of the client's negative behavior, it uses commanding language ("you better go to your room"), which can be perceived as aggressive and may escalate the situation instead of facilitating effective communication.

Choice D rationale:

This statement is the most effective example of assertive communication. It acknowledges the client's feelings ("I understand that you are angry") while also asserting the nurse's adherence to protocol. This response demonstrates empathy, understanding, and a willingness to address the client's emotions in a non-confrontational manner.

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Correct Answer is B

Explanation

Choice A rationale:

Current rehabilitation for opiate addiction is not typically associated with Wernicke-Korsakoff syndrome. Wernicke-Korsakoff syndrome is primarily linked to chronic alcohol abuse and thiamine deficiency.

Choice B rationale:

A personal history of alcohol use disorder is directly associated with Wernicke-Korsakoff syndrome. This syndrome is caused by thiamine (Vitamin B1) deficiency, which is commonly seen in individuals who have a history of heavy and chronic alcohol consumption.

Choice C rationale:

Undergoing current treatment for HIV is not a typical factor associated with the development of Wernicke-Korsakoff syndrome. This syndrome's primary cause is thiamine deficiency resulting from alcohol misuse.

Choice D rationale:

Family history of Alzheimer's disease is not a characteristic linked to Wernicke-Korsakoff syndrome. These two conditions have different etiologies and clinical presentations. Wernicke-Korsakoff syndrome is caused by thiamine deficiency, while Alzheimer's disease is a neurodegenerative disorder.

A. Attempt to talk the client down. B. Administer a PRN antianxiety medication. C. Place the client in a monitored seclusion room until he is calm. D. Restrain the client to prevent injury to himself or others.

Correct Answer is A

Explanation

Choice A rationale:

Attempting to talk the client down is the priority action in this situation. Agitation can escalate to aggression or violence if not addressed appropriately. Engaging in therapeutic communication can help de-escalate the client's agitation, express understanding, and potentially find out the underlying cause of their distress. This approach prioritizes a non-pharmacological intervention.

Choice B rationale:

Administer a PRN antianxiety medication. While medication might be a consideration for managing agitation, it's generally not the first action to take. Non-pharmacological interventions, like therapeutic communication, should be attempted first to minimize the reliance on medications to manage behaviors.

Choice C rationale:

Place the client in a monitored seclusion room until he is calm. Placing a client in seclusion should be a last resort and should only be done when there's an immediate risk of harm to the client or others. In this scenario, the client's agitation doesn't seem to present an imminent danger, so seclusion would be an excessive and restrictive intervention.

Choice D rationale:

Restrain the client to prevent injury to himself or others. Restraint should be an absolute last resort and only used when there's an imminent risk of harm that cannot be managed in any other way. Restraint can escalate agitation and trauma for the client, as well as pose legal and ethical concerns. Therefore, it should only be used when all other options have been exhausted and safety is a critical concern.

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A nurse in a mental health facility is caring for a client who is upset about the loss of privileges due to repetitive negative behavior. Which of the following statements by the nurse demonstrates the effective use of assertive communication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting a health history on a client who has a diagnosis of Wernicke-Korsakoff syndrome. The nurse recognizes that which of the following is an expected history associated with Wernicke-Korsakoff syndrome?

Correct Answer is B

Explanation

A nurse on a mental health unit notices that a client is becoming increasingly agitated and throws a table when he is unable to select the television (TV) channel. Which of the following should be a priority action by the nurse?

Correct Answer is A

Explanation

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