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 C
Explanation
The correct answer is Choice C.
Choice A rationale: Planning a therapeutic diet is essential for the client's recovery. However, it is not the first priority. Understanding the client's nutritional needs and current deficiencies should come before creating a diet plan.
Choice B rationale: Providing a structured environment is important to ensure the client follows the treatment plan and receives the appropriate support. However, it comes after assessing the client's current state and needs.
Choice C rationale: Assessing the client's nutritional status is the first priority because it provides critical information about the client's current health and guides all other aspects of care. Without knowing the client's nutritional status, it is challenging to make informed decisions about her treatment plan.
Choice D rationale: Requesting a mental health consult is important, especially given the client's belief that she is fat and the significant weight loss. However, before addressing her psychological needs, the nurse must understand her physical health status to provide comprehensive care.
Correct Answer is D
Explanation
Answer is d. Maintain eye contact with the client and summarize the client’s feelings.
a. Identify other housing options and sources of transportation: While it is essential to address practical needs such as housing and transportation for clients who have experienced a crisis like a house fire, it is not the immediate priority when the client is in acute emotional distress. In this scenario, the client is expressing emotional distress and may not be ready to focus on practical solutions. Therefore, addressing the client's emotional needs should take precedence over addressing practical concerns.
b. Notify the facility chaplain to request scheduling an appointment: While spiritual support can be beneficial for individuals coping with trauma or loss, it should not be the immediate response when a client is in acute emotional distress. While the chaplain's support may be sought later as part of the client's holistic care, it should not precede addressing the client's immediate emotional needs.
c. Confirm that everything will be all right because belongings can be replaced: This option is incorrect because it offers false reassurance and dismisses the client's feelings about their loss. While it is true that belongings can be replaced, the emotional impact of losing possessions, especially in a traumatic event like a house fire, should not be trivialized. The client's feelings of distress and uncertainty are valid and should be acknowledged and addressed by the nurse.
d. Maintain eye contact with the client and summarize the client’s feelings: Correct. This action demonstrates therapeutic communication, which is crucial in providing an atmosphere of support and safety for the client. Maintaining eye contact shows empathy, support, and advocacy, indicating to the client that their feelings are being heard and validated. Summarizing the client's feelings allows the nurse to demonstrate active listening and understanding, fostering trust and rapport between the nurse and client. By prioritizing the client's emotional needs, the nurse can help the client begin to process their feelings and move towards coping and problem-solving.
In summary, the correct answer is d because maintaining eye contact with the client and summarizing their feelings demonstrates therapeutic communication, which is essential in providing support and validation for the client's emotional distress. This approach allows the nurse to establish rapport and trust with the client, facilitating further therapeutic interventions and support.
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