A nurse in a mental health facility is interacting with a client who is angry and becoming increasingly aggressive. Which of the following actions should the nurse take?
Use clarification to determine what the patient is feeling.
Never break constant eye contact with the patient.
Move the patient to a private area so the conversation will not be disturbed and cannot be seen.
Speak to the patient using an authoritative voice and ask them, "Why are you acting this way?”
The Correct Answer is A
Choice A rationale:
When dealing with an angry and aggressive client, using clarification is an essential communication technique. It involves asking open-ended questions to better understand the patient's emotions and concerns, which can help defuse the situation and provide insight into the underlying issues.
Choice B rationale:
Maintaining constant eye contact can be interpreted as confrontational or aggressive behavior, potentially escalating the client's aggression. It's important to maintain a respectful distance and avoid behaviors that could exacerbate the situation.
Choice C rationale:
Moving the patient to a private area is a reasonable approach if the environment is contributing to the patient's agitation. However, the primary concern should be the safety of both the patient and the staff. Privacy can be important, but it shouldn't compromise safety.
Choice D rationale:
Speaking to the patient with an authoritative voice and asking "why" questions can escalate the situation further. It may come across as confrontational and provoke a defensive reaction from the patient. Open-ended questions that encourage the patient to express their feelings can be more effective in de-escalation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Erotomanic.
Choice A rationale:
Persecution. Persecutory delusions involve the belief that one is being targeted, harmed, or conspired against by others. This choice is not applicable in this scenario because the client is not expressing fear or belief that they are being persecuted.
Choice B rationale:
Erotomanic. Erotomanic delusions involve the false belief that someone, often of higher social status, is in love with the individual. In this case, the client's statement about being engaged to the Prince of England suggests an erotomanic delusion. The client is holding a grandiose belief that they are romantically involved with someone of prominence.
Choice C rationale:
Somatic. Somatic delusions involve the belief that there is something physically wrong with the individual's body. These delusions often manifest as the belief in having an illness or defect that is not actually present. The client's statement does not revolve around physical health or bodily concerns, making somatic delusion an unlikely option.
Choice D rationale:
Control. Control delusions involve the belief that one's thoughts, feelings, or actions are being controlled by external forces. This choice is not applicable in this scenario, as the client's statement does not indicate any perceived loss of control over their thoughts or actions.
Correct Answer is B
Explanation
The correct answer is choice B. A room containing personal belongings.
Choice A rationale:
Similar to the rationale provided for , a room without a window would not provide the necessary sensory input and connection to the outside world. Natural light and visual stimuli are important for maintaining a sense of time and orientation.
Choice B rationale:
A room containing personal belongings is the correct answer for the same reasons as mentioned in the previous question. Familiar items can provide comfort and reduce feelings of agitation in cognitively impaired individuals.
Choice C rationale:
Once again, a room adjacent to the nursing station could expose the client to unnecessary noise and activity, potentially causing distress and hindering the therapeutic environment required for cognitively impaired individuals.
Choice D rationale:
Dim lighting can contribute to disorientation and confusion. Adequate lighting helps individuals perceive their surroundings and reduces the risk of accidents.
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