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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A."You've been feeling that your life has no meaning."This response reflects active listening and acknowledges the client's emotions. Itreflects the client's feelings and encourages them to express more about their emotions and thoughts. It shows empathy and understanding, which can help build trust and rapport.
B. "You have a great deal to live for" may seem dismissive and does not address the client's current feelings of worthlessness.
C. "It's not unusual for depressed people to feel that way" can come across as minimizing the client's unique experience and does not provide support or encourage further discussion.
D. "Why do you feel you are worthless?" might make the client feel defensive or overwhelmed, and it does not offer the same level of empathy and support as reflecting their feelings would.
Correct Answer is B
Explanation
A) Decreased display of emotions:
While changes in emotional expression can occur in individuals with dementia, it's not a primary manifestation that is typically emphasized when educating families. Behavioral and psychological symptoms, including changes in emotion and personality, can be seen in dementia, but forgetfulness progressing to disorientation is a more direct and characteristic symptom of the condition.
B) Forgetfulness gradually progressing to disorientation
Explanation:
When educating the family of a client with dementia, the nurse should inform them to expect forgetfulness that gradually progresses to disorientation. Dementia is a progressive cognitive decline that affects memory, thinking, and reasoning. Forgetfulness is often one of the initial symptoms of dementia, and as the condition advances, individuals can become disoriented to time, place, and even people. This progression occurs due to the degeneration of brain cells and the accumulation of abnormal proteins.
C) Personality traits that are opposite of original traits:
Changes in personality traits can indeed occur as a result of dementia, but this may not be the most prominent or early manifestation that the nurse would want to highlight when educating the family. The gradual progression of forgetfulness leading to disorientation is a more specific and foundational aspect of dementia.
D) Decreased auditory and visual acuity:
Decreased sensory acuity, such as auditory and visual acuity, can happen with age and various health conditions, but they are not primary manifestations of dementia. Dementia primarily affects cognitive functions like memory, thinking, and reasoning.
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