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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The appropriate response for the nurse in this situation would be: "I'll just sit here with you for a few minutes then."
This response acknowledges the client's expressed desire not to talk and respects their boundaries. It shows support and presence by offering companionship without pressuring the client to discuss their feelings. The nurse's willingness to sit with the client demonstrates empathy and provides a sense of comfort and reassurance.
The other options are not as appropriate:
1. "It might help you feel better if you talk about it." This response disregards the client's stated preference not to talk and may create a sense of pressure or intrusiveness. It is important to respect the client's autonomy and readiness to share their feelings.
2. "Why are you feeling so down?" This response directly asks the client to explain their feelings, which they have already indicated they do not want to discuss. It can be seen as intrusive and may make the client feel uncomfortable or defensive.
3. "I understand. I've felt like that before, too." While empathy is important, this response brings the focus back to the nurse's own experiences, potentially diverting the attention from the client. It is important for the nurse to remain focused on the client's needs and create a supportive environment for them to express their feelings if they choose to do so.
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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