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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A reason: Assertiveness training is typically used to help individuals communicate more effectively and assert their needs and rights while respecting others. However, for someone with narcissistic personality disorder (NPD), this approach may not address the core issues of grandiosity and lack of empathy.

Choice B reason: Response prevention therapy is often used in the treatment of obsessive-compulsive disorder to help prevent the individual from engaging in compulsive behaviors. It is not typically indicated for NPD, as it does not address the underlying issues of self-esteem and empathy.

Choice C reason: Schema-focused therapy is designed to help individuals with NPD by identifying and changing deeply ingrained patterns of thinking and behavior, known as schemas, that are often maladaptive. This therapy can help address the root causes of NPD, such as feelings of inadequacy and the need for admiration, making it a suitable recommendation for someone with NPD³.

Choice D reason: Cognitive behavioral therapy (CBT) can be effective for a range of mental health disorders by helping individuals recognize and change negative thought patterns. While CBT can be beneficial for someone with NPD, schema-focused therapy is often preferred because it goes deeper into the personality structure and addresses the specific challenges of NPD³.

A. The client appears to be well-groomed B. The client’s current weight is 54 kg (119 lb.) C. The client states they are sleeping 5 to 6 hours per night, but having an occasional nightmare D. The client verbalizes a decreased appetite and gastrointestinal discomfort E. The client states, “I feel anxious about leaving my house. I feel like everyone is staring at me and judging me.” F. The client verbalizes that bullying experienced during high school has led to anxiety G. The client engages in thought-stopping behavioral therapy and cognitive restructuring H. The client reports taking escitalopram 20 mg daily, 2 hours after breakfast

Correct Answer is ["A","C","G","H"]

Explanation

Being well-groomed can be an indicator of improved mental health, as it suggests the client is taking care of their personal hygiene and appearance, which can be neglected during severe anxiety episodes.

An increase in the amount of sleep and a decrease in the frequency of nightmares can be seen as an improvement in the client’s condition, as sleep disturbances are common in anxiety disorders.

Engagement in thought-stopping behavioral therapy and cognitive restructuring indicates that the client is actively participating in therapeutic activities designed to manage anxiety, which is a positive sign of improvement.

Consistent medication adherence, as reported by the client taking escitalopram 20 mg daily, is crucial for managing anxiety symptoms and indicates the client’s commitment to following the treatment plan.

The client’s weight remaining stable could be neutral, as it does not indicate a significant change. Verbalizing decreased appetite and gastrointestinal discomfort, feeling anxious about leaving the house, and stating that past bullying has led to anxiety are all signs that the client is still experiencing symptoms of anxiety. Therefore, these choices do not reflect an improvement in the client’s condition.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has narcissistic personality disorder. Which of the following treatments should the nurse recommend?

Correct Answer is C

Explanation

Correct Answer is ["A","C","G","H"]

Explanation

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