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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The response "I will assist you in getting out of bed and getting dressed" demonstrates a supportive and therapeutic approach. It acknowledges the client's current state and offers assistance to engage in self-care activities. By providing support and actively participating in the client's care, the nurse can promote motivation, engagement, and a sense of empowerment.

The response "You can remain in bed until you feel well enough to join the milieu" may enable the client's depressive behaviors and reinforce the avoidance of activities. It does not encourage participation or provide support for the client to engage in therapeutic activities.

The response "The unit rules state that clients may not remain in bed" focuses on enforcing rules rather than addressing the client's underlying emotional state and needs. It may increase resistance and hinder the therapeutic relationship.

The response "If you don't participate in your care, you will not get better" may be perceived as blaming or judgmental. It may increase the client's guilt or sense of failure and does not provide practical support or encouragement.

A. “I know you will do well living out in the community." B. "I will send you a note in a few weeks." C. "Aren't you excited about being discharged today?" D. "How do you feel about being discharged?"

Correct Answer is D

Explanation

Asking the client how they feel about being discharged encourages open communication and provides an opportunity for the client to express their emotions and thoughts about leaving the

hospital. It shows that the nurse values the client's perspective and allows for further discussion and support if needed. This response promotes client-centered care and acknowledges the client's experience during the hospitalization.

The other options are less appropriate:

A. "I know you will do well living out in the community" assumes the client's feelings and may not accurately reflect their experience or emotions about the discharge.

B. "I will send you a note in a few weeks" focuses on the nurse's future action rather than actively engaging with the client's expression of gratitude.

C. "Aren't you excited about being discharged today?" assumes the client's emotional state and may not consider the potential range of emotions the client could be experiencing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newly admitted female client who has depression and refuses to get out of bed, dress, or participate in group therapy. Which of the following is an appropriate nursing response?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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