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A nurse is assisting with the care of a client.

The nurse is contributing to the plan of care for the client. Which of the following interventions should the nurse include in the plan? Select 5 interventions the nurse should include in the plan.

Teach behavior modification techniques.

Place the client in isolation.

Limit client privileges on the unit.

Touch the client's arm for reassurance.

Use nonthreatening body language when addressing the client.

Confront the client's aggressive behavior.

Redirect the client to an appropriate activity.

Role play responses to offensive behavior.

Provide structure and boundaries for the client.

Answer and Explanation

Correct Answer : A,C,E,G,I

A. Teach behavior modification techniques: Educating the client on behavior modification helps them recognize triggers, manage anger, and develop socially acceptable ways to express emotions. This aligns with cognitive-behavioral therapy goals and promotes long-term behavior change.

B. Place the client in isolation: This is not indicated unless the client is actively violent or poses imminent danger. Isolation can worsen anger and feelings of rejection.

C. Limit client privileges on the unit: Restricting privileges in response to aggressive or destructive behavior provides immediate feedback and reinforces accountability. This intervention sets clear expectations while maintaining safety and therapeutic boundaries.

D. Touch the client's arm for reassurance: Never touch an agitated or aggressive client; this may be perceived as threatening and escalate aggression.

E. Use nonthreatening body language when addressing the client: Approaching the client calmly with open posture, relaxed tone, and controlled gestures reduces the risk of escalation. Nonthreatening body language fosters a safe therapeutic environment and helps de-escalate anger or aggression.

F. Confront the client's aggressive behavior: Confrontation increases defensiveness and may escalate aggression. Therapeutic communication focuses on redirection and de-escalation instead.

G. Redirect the client to an appropriate activity: Redirection helps the client manage impulses and engage in safe, structured activities. This approach reduces opportunities for aggression and destructive behavior while promoting participation in therapeutic interventions.

H. Role play responses to offensive behavior: Helpful later in therapy, but not appropriate during acute aggression or treatment refusal. The client currently refuses therapy and is unstable; role-play is not a priority intervention at this phase.

I. Provide structure and boundaries for the client: Establishing clear rules, routines, and expectations helps the client understand limits and consequences. Structure and consistent boundaries are essential for managing aggression, promoting safety, and supporting behavioral improvement.

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Correct Answer is ["A","B","C","D"]

Explanation

A. Terminal liver cancer: Chronic or terminal illnesses can increase the risk of suicide due to pain, loss of independence, and feelings of hopelessness. Clients facing life-limiting conditions may experience emotional distress that contributes to suicidal ideation.

B. Sibling history of suicide: A family history of suicide is a known risk factor, as genetic predisposition and learned behaviors can increase vulnerability. Having a sibling who died by suicide elevates the client’s risk compared to the general population.

C. Access to guns in the home: Ready access to lethal means, such as firearms, significantly increases the risk of suicide. The presence of guns facilitates impulsive actions and higher fatality rates in suicide attempts.

D. Alcohol use disorder: Alcohol impairs judgment, increases impulsivity, and can exacerbate depression, all of which heighten suicide risk. Substance use disorders are commonly associated with suicidal behavior and attempts.

E. Currently married: Being married is generally considered a protective factor against suicide due to social support and connectedness. Marriage alone does not increase suicide risk and often decreases vulnerability compared to isolation or single status.

A. Bring a security guard whenever approaching the client. B. Use a calm, clear tone when speaking to the client. C. Encourage the client to participate in a board game. D. Touch the client on the shoulder to console them.

Correct Answer is B

Explanation

A. Bring a security guard whenever approaching the client: Involving security unnecessarily can escalate tension and reinforce hostile behavior. Safety is important, but this intervention should be reserved for situations where the client poses an immediate physical threat.

B. Use a calm, clear tone when speaking to the client: Maintaining a calm, clear, and neutral tone helps de-escalate hostility and reduces the likelihood of verbal or physical aggression. Clear communication also sets boundaries while promoting a therapeutic environment for clients with schizophrenia.

C. Encourage the client to participate in a board game: While engaging in structured activities can be beneficial for socialization and distraction, this intervention does not directly address the immediate hostile outbursts or prevent escalation. It is more of a supportive measure than a priority intervention.

D. Touch the client on the shoulder to console them: Physical touch can be misinterpreted by clients with schizophrenia, potentially triggering anxiety, agitation, or further hostility. Nonverbal boundaries should be maintained unless the client explicitly consents to touch in a therapeutic context.

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A nurse is assisting with the care of a client. The nurse is contributing to the plan of care for the client. Which of the following interventions should the nurse include in the plan? Select 5 interventions the nurse should include in the plan.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is contributing to the plan of care for a client who has schizophrenia. The client often directs brief, hostile verbal outbursts toward the staff. Which of the following interventions should the nurse recommend?

Correct Answer is B

Explanation

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A nurse is assisting with the care of a client.

The nurse is contributing to the plan of care for the client. Which of the following interventions should the nurse include in the plan? Select 5 interventions the nurse should include in the plan.