A nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unit. Which of the following actions should the nurse take first?

Explain the client that the behavior was unacceptable.

Explore the truth of the client's statements.

Set behavioral limits for the client.

Establish a client relationship

Answer and Explanation

The Correct Answer is C

A. Explain to the client that the behavior was unacceptable: While addressing the behavior is important, it is more effective to first establish clear limits and boundaries to prevent further incidents.

B. Explore the truth of the client’s statements: This step involves assessing the client's statements and understanding their perspective, which is important but can be done after setting behavioral limits.

C. Set behavioral limits for the client: Establishing clear behavioral limits is crucial for maintaining safety and order in the psychiatric unit. It helps ensure that the client understands what is expected of them and the consequences of unacceptable behavior. This is particularly important if the client has exhibited aggressive behavior, as it helps prevent further incidents and maintains a safe environment for everyone.

D. Establish a client relationship: Building a therapeutic relationship is essential for effective treatment, but it should be done in the context of a safe environment where clear behavioral expectations have already been established.

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Correct Answer is D

Explanation

A. "We can call your family in time for them to get here."

While involving the family is important, this response assumes that the client's concern is solely about family being present. The client's statement might have deeper emotional layers, such as fear or regret, that should be addressed.

B. "Tell your family of your concern so that they can be here."

This response puts the responsibility on the client to communicate their concerns to the family. The nurse's role is to provide support and facilitate communication, rather than placing the burden on the client.

C. "I will make sure a staff member is in your room at all times."

While ensuring the client is not alone is important, this response doesn't address the client's emotional concerns or open a dialogue about their feelings. Simply having a staff member present might not address the underlying fear or anxiety the client is experiencing.

D. "I wonder if you are fearful of dying alone."

Explanation: The nurse's response empathizes with the client's feelings and invites a conversation about their emotions. It acknowledges the client's concerns and opens the door for a more in-depth discussion about their fears and feelings regarding dying alone. This approach is patient-centered and encourages the client to express their emotions.

A. I can be on my antidepressant taking three to five days to be effective B. I can cure my depression by thinking positive thoughts." C. I will attend psychotherapy to help manage my depression," D. "I need to make a voluntary choice to stop feeling depressed."

Correct Answer is C

Explanation

A. Antidepressants usually take several weeks to start taking effect, so the statement "I can be on my antidepressant taking three to five days to be effective" is not correct.

B. While positive thinking can play a role in managing mood, depression is a complex disorder that often requires more than just positive thoughts to treat. The statement "I can cure my depression by thinking positive thoughts" oversimplifies the condition.

C. "I will attend psychotherapy to help manage my depression."

Explanation:

Depressive disorders, including major depression, are complex conditions that typically require a multifaceted approach to treatment. Psychotherapy, also known as talk therapy, is an important component of treating depression. It involves working with a trained therapist to explore and address the thoughts, feelings, and behaviors contributing to the depression. Psychotherapy can help individuals develop coping strategies, improve problem-solving skills, and gain insight into their condition.

D. Depression is not something that can be simply chosen to be stopped voluntarily. It is a mental health disorder that often requires professional treatment and support. The statement "I need to make a voluntary choice to stop feeling depressed" does not accurately capture the nature of depression.

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A nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unit. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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