A nurse is assisting in the admission process for a client who has a history of violent behavior. The client stands up and begins clenching her fists and arguing with the nurse. Which of the following actions is the priority?

Explore the truth of the client's statements.

Establish a therapeutic nurse-client relationship.

Set behavioral limits for the client

Show the client around the unit and introduce her to other clients.

Answer and Explanation

The Correct Answer is C

The priority action in this situation is to set behavioral limits for the client. This is important for maintaining a safe environment for the client, other staff members, and other clients. By setting limits, the nurse establishes clear boundaries and expectations for behavior, helping to prevent the escalation of aggression or violence.
Let's examine why the other choices are incorrect:

A. Exploring the truth of the client's statements: While it is important to listen to and validate the client's concerns, in this particular situation, where the client is becoming agitated and confrontational, addressing the truth of their statements is not the priority. The immediate concern is ensuring safety and de-escalating the situation.

B. Establishing a therapeutic nurse-client relationship: Developing a therapeutic relationship is crucial for providing effective care, but it may not be the immediate priority when a client is displaying aggressive or violent behavior. Safety takes precedence in such situations, and setting behavioral limits is necessary before establishing a therapeutic relationship can effectively occur.

D. Showing the client around the unit and introducing her to other clients: This action is inappropriate during an agitated and confrontational episode. It is important to first
address the client's behavior and ensure the safety of all individuals involved before engaging in social activities or introductions.

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Correct Answer is C

Explanation

This response acknowledges the client's subjective experience and validates their belief that the bracelet provides pain relief. It shows empathy and respect for the client's perspective without dismissing or challenging their belief.

Let's review the other options and explain why they are not the most appropriate responses:

A. "Why do you think the copper helps with your arthritis?" This response may come across as questioning or doubting the client's belief, which can be invalidating and may hinder the

nurse-client relationship.

B. "I think you should rely more on your medication therapy than on your bracelet." While it is important to emphasize evidence-based medical treatments, this response may be perceived as dismissive or confrontational. It is essential to maintain a supportive and collaborative approach.

D. "Believing objects have powers to make you feel better has no scientific basis." Although this statement is true in terms of scientific evidence, it may undermine the client's beliefs and create a sense of defensiveness or disagreement. It is more effective to maintain a respectful and non-judgmental attitude.

A. The client trains his mind to relax by using deep inner resources. B. The client learns the source of his stress by writing down daily events. C. The client imagines being in a quiet, relaxing environment. D. The client learns to change negative thoughts into positive statements.

Correct Answer is D

Explanation

Effective use of cognitive reframing involves shifting negative thoughts or perspectives into more positive and realistic ones. By learning to change negative thoughts into positive statements, the client is actively engaging in cognitive reframing techniques. This process allows the client to challenge and reframe negative thinking patterns, which can help reduce stress and promote a more positive outlook.

Incorrect:

A. Training the mind to relax by using deep inner resources is a helpful technique for relaxation and stress reduction. However, it does not specifically involve cognitive reframing, which focuses on modifying thought patterns and perspectives.

B. Learning the source of stress by writing down daily events can be a useful tool for

self-awareness and understanding triggers. While it may contribute to stress management, it does not directly involve cognitive reframing.

C. Imagining being in a quiet, relaxing environment can be a relaxation technique that helps reduce stress. However, it is not specifically related to cognitive reframing, which centers on changing thought patterns.

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A nurse is assisting in the admission process for a client who has a history of violent behavior. The client stands up and begins clenching her fists and arguing with the nurse. Which of the following actions is the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has rheumatoid arthritis shows the nurse at her provider's office her magnetic copper bracelet and says that it helps alleviate her pain when she wears it. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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