A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should the nurse take?

Discuss the problem in a community meeting with the other clients on the unit present.

Escort the client to her room each time the nurse observes the client socializing with other clients.

Talk to the client and identify the specific limits that are required of the client's behavior.

Tell the other clients to ignore the client's lies

Answer and Explanation

The Correct Answer is C

A. Discuss the problem in a community meeting with the other clients on the unit present.

While open communication and community meetings can be valuable in certain situations, discussing a client's disruptive behavior in front of others may breach their privacy and dignity. It's important to address such matters privately and respectfully.

B. Escort the client to her room each time the nurse observes the client socializing with other clients.

This action might be seen as overly punitive and restrictive. Isolating the client based on their behavior without addressing the underlying issues doesn't promote a therapeutic approach to the situation.

C. Talk to the client and identify the specific limits that are required of the client's behavior.

This is the correct option. Talking to the client directly allows the nurse to address the behavior, express expectations, and set clear boundaries. This approach promotes open communication and gives the client a chance to understand how their actions are affecting others.

D. Tell the other clients to ignore the client's lies.

While it's important to encourage other clients to manage their reactions to disruptive behavior, simply telling them to ignore lies might not address the root cause of the issue. The nurse should aim to address the behavior itself and create an environment where all clients feel respected and safe.

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Correct Answer is D

Explanation

A. "Let's try to find ways to incorporate your partner's favorite food into her diet plan."

While it's important to consider the client's preferences, dietary restrictions are often in place for specific health reasons. Trying to incorporate forbidden foods into the diet plan might compromise the client's health and recovery.

B. "Why would you want to put your partner's health at further risk?"

This response is confrontational and may not foster a productive conversation with the partner. It's important to address the situation professionally and collaboratively.

C. "Everyone likes food from home, but it can delay your partner's recovery."

While this response acknowledges the partner's feelings, it's essential to communicate more directly about involving the healthcare provider in decisions about the client's diet.

"D. You will need to discuss your concerns about your partner's diet with the provider."

Explanation: In matters involving a client's dietary plan and health, it's important to involve the healthcare provider to make informed decisions. The nurse should guide the partner to communicate their concerns with the provider who has the authority to evaluate the situation, consider the dietary restrictions, and make a decision that aligns with the client's health and recovery.

A. Attention-seeking conduct B. Wild fidgeting C. Threatening behavior D. Mild difficulty problem solving

Correct Answer is B

Explanation

A.In the context of severe anxiety, clients might engage in attention-seeking behaviors as a way to express their distress or seek support. However, wild fidgeting remains a more direct and common manifestation of severe anxiety.

B.Severe anxiety can lead to various physical and psychological manifestations. "Wild fidgeting" is a common physical manifestation of severe anxiety. It involves restlessness, rapid movements, and an inability to sit still. Fidgeting can be a way for individuals to release excess energy and manage their heightened anxiety levels.

C.While severe anxiety can lead to a variety of behaviors, threatening behavior is not a typical or direct manifestation of severe anxiety. Such behavior may be more indicative of other mental health issues or agitation.

D.Severe anxiety is more likely to cause impairments in concentration, focus, and problem-solving abilities rather than mild difficulty. Severe anxiety can lead to cognitive overload and make it challenging for individuals to think clearly and solve problems effectively.

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A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

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