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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The statement "Providers are required to warn individuals if the client threatens harm" demonstrates an understanding of the legal exception known as the duty to warn or protect. It means that if a client expresses an intent to harm themselves or others, healthcare providers have a legal obligation to take appropriate actions, which may include notifying potential victims or authorities.
Incorrect:
1. "The legal requirement for client confidentiality does not apply if the client is deceased." - This statement is incorrect. Client confidentiality extends even after a client's death, and healthcare professionals are still expected to maintain confidentiality regarding the client's health information.
2. "Staff members are required to divulge information regarding a client's hospitalization to a client's employer." - This statement is incorrect. Healthcare professionals are required to maintain client confidentiality and cannot disclose a client's health information to their employer without the client's explicit consent or as mandated by specific legal requirements.
3. "Healthcare workers can use client confidentiality for their own legal defense." - This statement is incorrect. Client confidentiality is meant to protect the client's privacy and
maintain trust. It cannot be used by healthcare workers as a defense mechanism in legal matters.
Correct Answer is C
Explanation
This statement implies that the nurse is taking sides and suggesting a specific course of action to the client. It is important for the nurse to remain neutral and non-directive during family therapy sessions. The nurse's role is to facilitate open communication, active listening, and understanding between the family members, rather than imposing their own opinions or suggesting specific solutions.
To ensure a therapeutic and unbiased approach, the nurse should intervene and provide feedback to the newly licensed nurse, reminding them to maintain a neutral stance and encourage the client to explore their own perspectives and feelings about the relationship.
Incorrect:
A. "We should invite your partner to be a part of our discussion." This statement suggests involving the partner, which is a common practice in family therapy. It recognizes the importance of including all relevant family members in the therapeutic process.
B. "Tell me about the concerns that you have regarding your relationship." This statement encourages the client to express their concerns and provides an opportunity for them to share their thoughts and feelings about the relationship. It promotes open communication and active listening.
D. "Relationship difficulties are stressful and require effort to resolve." This statement acknowledges the challenges in relationships and emphasizes the need for active participation and effort to address and resolve issues. It sets a realistic expectation for the client and supports their engagement in the therapeutic process.
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