A nurse is preparing to change the dressing on the lower leg of an older adult client who is in a wheelchair, and has a history of maladaptive coping skills. The client begins swearing at and verbally abusing the nurse. Which of the following actions should the nurse take?

Explain to the client why her behavior is inappropriate.

Tell the client when he will return and leave the room.

Place wrist restraints on the client to prevent psychomotor agitation.

Move the client to a seclusion room.

Answer and Explanation

The Correct Answer is B

By calmly informing the client when the nurse will return and then leaving the room, the nurse establishes clear boundaries and removes themselves from the situation to ensure their own safety. It allows the nurse to disengage from the abusive behavior and avoid escalating the situation further.

Let's review the other options and explain why they are not appropriate in this situation:

A. Explaining to the client why their behavior is inappropriate may not be effective in the moment when the client is already agitated and verbally abusive. Attempting to reason with or educate the client during this state could potentially escalate the situation or prolong the abusive behavior.

C. Placing wrist restraints on the client should only be done in exceptional circumstances when there is an imminent risk of harm to themselves or others. Verbal abuse, while unpleasant, does not necessarily warrant the use of restraints as a first-line intervention.

D. Moving the client to a seclusion room is also an extreme measure and should only be considered if the client's behavior poses a significant risk to themselves or others and less restrictive interventions have been exhausted. Verbal abuse alone would not typically warrant seclusion.

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Correct Answer is D

Explanation

Regression is a defense mechanism that involves reverting to an earlier stage of development or behaving in a way that is characteristic of an earlier developmental level in response to stress or anxiety. It is a way for individuals to cope with overwhelming emotions or situations by retreating to a previous, more comfortable state.

In the scenario described, the client's behavior of consistently being late for appointments and ignoring household chores while expressing the need to be taken care of indicates a regressive response to stress. By relying on others to take care of their responsibilities, the client is seeking a sense of security and support, similar to how they may have relied on others in the past, such as during childhood.

Inc

A- Repression involves the unconscious blocking of unacceptable thoughts or impulses from conscious awareness.

B- Introjection is the internalization of values or qualities of another person or group.

C- Dissociation is a defense mechanism that involves detaching oneself from reality or the present moment to avoid emotional distress.

A. "The most common adverse effects of ECT are related to the anesthesia." B. "You might feel a bit confused and disoriented when you first wake up." C. "You should expect to have ECT once per week for 6 weeks." D. "You may experience muscle cramping from the induced seizure."

Correct Answer is B

Explanation

Electroconvulsive therapy (ECT) is a procedure used to treat certain mental health conditions. When providing teaching to a client scheduled to receive ECT, it is important to provide accurate information about what they can expect during and after the procedure.

The statement "You might feel a bit confused and disoriented when you first wake up" is important because confusion and disorientation are common side effects of ECT. Clients often experience some memory loss and temporary cognitive impairment after the procedure, which can cause these symptoms. By preparing the client for these potential effects, the nurse helps reduce anxiety and ensures that the client understands what is considered normal post-ECT.

Incorrect:

A. "The most common adverse effects of ECT are related to the anesthesia." While anesthesia is used during ECT to ensure the client's comfort and safety, the most common adverse effects of ECT are related to the procedure itself, such as memory loss and cognitive changes.

C. "You should expect to have ECT once per week for 6 weeks." The frequency and duration of ECT treatments vary depending on the individual client's condition and treatment plan. It is not appropriate to provide a specific treatment schedule without knowing the client's unique circumstances.

D. "You may experience muscle cramping from the induced seizure." Muscle cramping is not a common adverse effect of ECT. The induced seizure is typically brief and controlled, and muscle relaxants are administered to prevent any excessive muscle activity during the procedure.

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A nurse is preparing to change the dressing on the lower leg of an older adult client who is in a wheelchair, and has a history of maladaptive coping skills. The client begins swearing at and verbally abusing the nurse. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who is scheduled to receive electroconvulsive therapy (ECT). Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

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