A nurse is caring for a client who becomes verbally abusive when the nurse enters her room. Which of the following actions should the nurse take?
Leave the client's room
Maintain eye contact until the behavior stops.
Tell the client her behavior is disappointing.
Punish the client for the behavior.
The Correct Answer is A
It is essential for the nurse's safety and well-being to remove themselves from a situation where the client is exhibiting verbally abusive behavior. Leaving the room allows the nurse to distance themselves from the confrontational environment and ensures their physical and emotional safety. Continuing to engage with the client may escalate the situation further and put the nurse at risk.
Incorrect:
B. Maintain eye contact until the behavior stops: Maintaining eye contact may be perceived as confrontational or provocative, which can further escalate the situation. It is advisable for the nurse to disengage from the client's presence to avoid potential harm.
C. Tell the client her behavior is disappointing: Engaging in a confrontational or judgmental response can exacerbate the client's anger or aggression. It is important for the nurse to maintain a professional and therapeutic approach while ensuring personal safety.
D. Punish the client for the behavior: Punishment is not an appropriate response to verbally abusive behavior. It can damage the nurse-client relationship and potentially worsen the client's emotional state. Promoting a supportive and therapeutic environment is key in managing challenging behaviors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is B
Explanation
Electroconvulsive therapy (ECT) is a procedure used to treat certain mental health conditions. When providing teaching to a client scheduled to receive ECT, it is important to provide accurate information about what they can expect during and after the procedure.
The statement "You might feel a bit confused and disoriented when you first wake up" is important because confusion and disorientation are common side effects of ECT. Clients often experience some memory loss and temporary cognitive impairment after the procedure, which can cause these symptoms. By preparing the client for these potential effects, the nurse helps reduce anxiety and ensures that the client understands what is considered normal post-ECT.
Incorrect:
A. "The most common adverse effects of ECT are related to the anesthesia." While anesthesia is used during ECT to ensure the client's comfort and safety, the most common adverse effects of ECT are related to the procedure itself, such as memory loss and cognitive changes.
C. "You should expect to have ECT once per week for 6 weeks." The frequency and duration of ECT treatments vary depending on the individual client's condition and treatment plan. It is not appropriate to provide a specific treatment schedule without knowing the client's unique circumstances.
D. "You may experience muscle cramping from the induced seizure." Muscle cramping is not a common adverse effect of ECT. The induced seizure is typically brief and controlled, and muscle relaxants are administered to prevent any excessive muscle activity during the procedure.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.