A nurse is admitting a client to the psychiatrist unit after attacking a neighbor. The nurse should know that the client can be kept in the hospital after the 72 hours hold is over when which of the following conditions is met?
The client is unwilling to accept the treatment being offered.
The client states that they will never attack the neighbor again.
The client plans to move out of state immediately upon discharge from the hospital.
The client is a threat to himself and others.
The Correct Answer is D
A client can be kept in the hospital after the initial 72-hour hold if they are deemed to be a threat to themselves or others. This determination is typically made by a mental health professional who evaluates the client’s behavior and mental state. If the client is considered to be a danger, they may be held involuntarily for further treatment and observation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Disassociation is a defense mechanism that involves mentally separating oneself from a stressful or traumatic situation in order to maintain a sense of calm and focus. In this scenario, the nurse is able to block out the sirens and alarms, which may be causing stress and anxiety, and maintain a calm and focused demeanor while speaking with the client's family. This is an adaptive use of disassociation because it allows the nurse to provide effective care and support to the family despite the chaotic environment.
Denial is a defense mechanism that involves denying or minimizing the existence of a stressful or traumatic situation. Rationalization involves justifying or excusing one's behavior or actions. Altruism involves selflessly helping others as a way of dealing with one's own problems. In this scenario, none of these defense mechanisms are being used by the nurse.
Correct Answer is C
Explanation
Tertiary prevention refers to interventions that are designed to reduce the impact of an ongoing illness or injury that has lasting effects. In this case, community mental health nurses have been sent to the area to provide intervention after a major hurricane has already occurred. Their goal is to help individuals and communities recover from the traumatic event and reduce the long-term impact on their mental health
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