A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply.)
Identify the client's stressors.
Talk to the client using short, simple sentences.
Speak to the client in a loud voice.
Request that security guards restrain the client.
Stand directly in front of the client.
Correct Answer : A,B
Choice A reason: Identifying the client's stressors is a crucial step in managing agitation. Understanding what triggers the client's distress can help the nurse to address the underlying issues and de-escalate the situation.
Choice B reason: Using short, simple sentences can help to communicate effectively with an agitated client. It ensures that the client can process the information without being overwhelmed, which is important for calming the situation.
Choice C reason: Speaking to the client in a loud voice is not recommended as it may escalate the situation. It's important to maintain a calm and soothing tone to avoid further agitation.
Choice D reason: Requesting that security guards restrain the client should be a last resort, only if the client poses an immediate threat to themselves or others. Less restrictive measures should be attempted first.
Choice E reason: Standing directly in front of an agitated client can be perceived as confrontational. It's better to maintain a non-threatening stance and ensure there is enough space to allow the client to feel safe.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B. Obtain a prescription for seclusion within 30 minutes. This ensures the seclusion is legally and ethically justified.
Choice A reason:
Keeping the client in seclusion for no longer than 6 hours is incorrect because the maximum duration for seclusion without reassessment is typically 4 hours for adults.
Choice B reason:
Obtaining a prescription for seclusion within 30 minutes is correct as it ensures the seclusion is legally and ethically justified.
Choice C reason:
Monitoring the client's vital signs every 4 hours is incorrect because vital signs should be monitored more frequently, usually every 15 minutes to 1 hour.
Choice D reason:
Documenting the client's behavior every 60 minutes is incorrect because documentation should occur more frequently, typically every 15 minutes.
Correct Answer is B
Explanation
Choice A reason: While sharing personal experiences can sometimes help in connecting with the grieving individual, it may also shift the focus away from the partner's feelings to the nurse's own experiences. It's important to keep the conversation centered on the partner's emotions and support needs.
Choice B reason: This response acknowledges the partner's feelings without judgment and opens the door for further conversation. It shows empathy and understanding, which are crucial in providing emotional support to someone who is grieving.
Choice C reason: Suggesting a grief counselor is a practical step, but it might be perceived as dismissive if offered too quickly. It's essential to first establish a supportive dialogue and understand the partner's readiness to seek additional help.
Choice D reason: Telling someone they shouldn't feel guilty can invalidate their feelings. Guilt is a common emotion in the grieving process, and it's important to acknowledge it and provide a safe space for the individual to express their feelings.
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