A nurse is planning care for a client who demonstrates manipulative behavior. Which of the following interventions should be included in the plan of care?
Avoid discussing past behaviors with the client.
Institute consequences for manipulative behavior.
Allow manipulation so as to not raise the client's anxiety.
Bargain with the client to discourage manipulative behavior.
The Correct Answer is B
Rationale:
Choice A: Avoid discussing past behaviors with the client is incorrect. While avoiding dwelling on the past is important, discussing past manipulative behaviors in a safe and therapeutic environment can help the client gain insight into their patterns and triggers. This awareness is crucial for developing future coping mechanisms and preventing further manipulation.
Choice C: Allow manipulation so as to not raise the client's anxiety is incorrect. Allowing manipulation reinforces the behavior and undermines the client's well-being. It also sets a dangerous precedent for interactions with others.
While addressing anxiety is important, it should not be at the cost of condoning manipulation.
Choice D: Bargain with the client to discourage manipulative behavior is incorrect. Bargaining implies making concessions in exchange for the client stopping their manipulation. This approach can be ineffective and even reinforce the manipulative behavior as the client learns to negotiate for desired outcomes. Instead, clear boundaries and consistent consequences are more effective in addressing manipulation.
Rationale for Choice B:
Instituting consequences for manipulative behavior provides a clear and consistent response to the client's actions. This can help to limit the behavior and encourage the client to develop alternative coping mechanisms.
Consequences should be:
Fair and proportional: The consequence should be related to the specific manipulative behavior and not be overly harsh or punitive.
Consistent: The same consequence should be applied each time the manipulative behavior occurs. This predictability helps the client understand the cause-and-effect relationship between their actions and the consequences.
Enforceable: The consequence should be something that can be realistically implemented and followed through on. While implementing consequences, it's important to:
Maintain a therapeutic relationship: Address the behavior in a calm and professional manner, focusing on the behavior itself and not personal attacks.
Communicate clearly: Explain the consequences to the client in advance and ensure they understand the connection between their actions and the outcome.
Provide alternative coping mechanisms: Offer the client support and guidance in developing healthier ways to express their needs and manage their emotions.
By setting clear boundaries and consistently implementing consequences, nurses can help clients with manipulative behaviors learn to interact in a more positive and productive way. This ultimately benefits the client, their relationships, and their overall well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E"]
Explanation
: The correct answer/s is Choice/s.
Choice A rationale: Phosphate level is a crucial indicator of the body’s electrolyte balance. In patients with anorexia nervosa, phosphate levels can be significantly affected due to malnutrition and the body’s metabolic response to starvation. Low phosphate levels, known as hypophosphatemia, can lead to serious complications such as muscle weakness, neurological dysfunction, and potentially life-threatening cardiac issues.
Choice B rationale: Capillary refill is a quick test performed on a patient to assess the adequacy of peripheral circulation. The time taken for color to return to an external capillary bed after pressure has been applied to cause blanching signifies the status of the patient’s peripheral blood circulation. Delayed capillary refill time may indicate shock or dehydration, which could be a concern in a patient with anorexia nervosa who may be dehydrated or malnourished.
Choice C rationale: Sodium level is another important electrolyte that needs to be monitored. Patients with anorexia nervosa can have abnormal sodium levels due to various factors such as vomiting, use of diuretics, or not consuming enough dietary sodium. Both high sodium (hypernatremia) and low sodium (hyponatremia) levels can lead to severe neurological symptoms and are considered medical emergencies.
Choice D rationale: Magnesium level is also an important consideration in patients with anorexia nervosa. Low magnesium levels, or hypomagnesemia, can occur due to inadequate dietary intake or excessive loss from the gastrointestinal tract, which can be seen in conditions like anorexia nervosa. Hypomagnesemia can lead to symptoms such as muscle cramps, seizures, and even cardiac arrhythmias.
Choice E rationale: Glucose level is a key indicator of a person’s metabolic state and energy balance. In patients with anorexia nervosa, glucose levels can be low due to inadequate food intake. Hypoglycemia, or low blood sugar, can lead to symptoms such as weakness, tremors, confusion, and in severe cases, it can be life-threatening.
Correct Answer is A
Explanation
Choice A rationale:
Protecting the client from injury is the highest priority nursing action in this scenario. Here's a detailed rationale explaining the importance of this action:
1. Imminent Risk of Harm:
Acute anxiety can significantly impair judgment and impulse control, escalating the risk of self-harm or harm to others. It's crucial to prevent any actions that could result in physical injury, even if unintended.
2. Physiological Manifestations:
Anxiety can trigger physiological responses that heighten the potential for harm, such as: Increased heart rate and blood pressure
Hyperventilation Diaphoresis
Agitation and restlessness Dissociation
These physiological changes can contribute to accidents, falls, or other injuries.
3. Impaired Decision-Making:
Acute anxiety often clouds rational thinking and decision-making abilities.
Individuals may engage in behaviors they wouldn't consider in a calmer state, such as running away, lashing out, or attempting self-harm.
The nurse's role is to safeguard the client from potential consequences of these impulsive actions.
4. Establishing Safety as a Foundation for Care:
Ensuring physical safety creates a necessary foundation for subsequent interventions.
Once safety is established, the nurse can proceed with assessing coping skills, identifying anxiety triggers, and implementing therapeutic strategies.
5. Protecting Others:
In rare cases, acute anxiety can manifest in aggression towards others.
The nurse must protect not only the client but also other individuals who may be at risk.
6. Ethical and Legal Obligations:
Nurses have a professional duty to protect clients from harm, upholding ethical principles and legal standards of care.
7. Preventing Trauma:
Physical injuries sustained during a crisis can exacerbate anxiety and complicate recovery. Proactive safety measures aim to prevent further trauma and promote healing.
I'll provide detailed rationales for the other choices in separate messages to ensure clarity and comprehensiveness.
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