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. "It sounds like you're having a difficult time."
Choice A rationale:
"How long has this been going on?" This question focuses on the duration of the client's symptoms, which might not be the most appropriate response at this point. The client's immediate emotional state and distress should be acknowledged before delving into the duration of the issue.
Choice B rationale:
"It sounds like you're having a difficult time." This response demonstrates empathy and understanding towards the client's emotional state. It acknowledges the client's feelings without making assumptions or probing for specific details. It provides a supportive environment for the client to open up further.
Choice C rationale:
"Have you talked to your parents about this yet?" This question assumes that the client's parents are a source of support and that the client has not yet spoken to them about their feelings. It also directs the conversation towards external parties instead of focusing on the client's immediate emotions.
Choice D rationale:
"Why do you think you are so anxious?" This question might come across as confrontational or demanding, potentially making the client defensive. It could hinder open communication and create a barrier between the nurse and the client.
Correct Answer is D
Explanation
Choice A rationale:
"This is supposed to happen when you get old, right?" is a common misconception but doesn't necessarily support the diagnosis of delirium. It could be attributed to normal aging changes.
Choice B rationale:
"Since his mother died, he has not been feeling well." indicates a potential stressor but doesn't directly address the rapid onset of behavioral changes, which is a hallmark of delirium.
Choice C rationale:
"My husband just didn't seem to know what he was doing. He has been forgetful for years." suggests a history of forgetfulness rather than an acute change in behavior, which is more indicative of chronic cognitive issues like dementia.
Choice D rationale:
(Correct) "The changes in his behavior came on so quickly! I wasn't sure what was happening." This statement supports the diagnosis of delirium, which is characterized by a sudden onset of confusion and changes in cognitive function. Delirium often develops rapidly, and the client's wife's observation aligns with this diagnostic criterion.
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