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
When planning an interview for a newly admitted client and deciding who to include, the nurse should use the method of including people whom the client views as family. It is important to consider the client's perception and definition of family, as this can vary from person to person. Family can include not only blood relatives or individuals related by marriage but also those who have significant emotional connections and provide support to the client.
Incorrect:
A. Including people who can support the client adequately: While it is essential to include individuals who can provide support to the client, support can come from various sources beyond family members. Including only those who can support the client adequately may exclude important individuals in the client's life who are not considered family but still play a significant role.
B. Including people who live in the same house with the client: While individuals living in the same house as the client may have daily interactions and involvement in the client's life, they may not necessarily be considered family by the client. It is crucial to consider the client's perception of family and include individuals based on that definition.
D. Including people who are related to the client by blood and marriage: While blood relatives and individuals related by marriage can be part of the client's family, limiting the inclusion to only these individuals may exclude others who are important to the client's support system.
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.
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.