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 C

Explanation

The statement "Providers are required to warn individuals if the client threatens harm" demonstrates an understanding of the legal exception known as the duty to warn or protect. It means that if a client expresses an intent to harm themselves or others, healthcare providers have a legal obligation to take appropriate actions, which may include notifying potential victims or authorities.

Incorrect:

1. "The legal requirement for client confidentiality does not apply if the client is deceased." - This statement is incorrect. Client confidentiality extends even after a client's death, and healthcare professionals are still expected to maintain confidentiality regarding the client's health information.
2. "Staff members are required to divulge information regarding a client's hospitalization to a client's employer." - This statement is incorrect. Healthcare professionals are required to maintain client confidentiality and cannot disclose a client's health information to their employer without the client's explicit consent or as mandated by specific legal requirements.
3. "Healthcare workers can use client confidentiality for their own legal defense." - This statement is incorrect. Client confidentiality is meant to protect the client's privacy and
maintain trust. It cannot be used by healthcare workers as a defense mechanism in legal matters.

A. Call housekeeping to clean up the lounge. B. Promise the client that the issue will be discussed at the next community meeting. C. Help the client clean up the dayroom. D. Encourage the client to discuss the problem with other clients.

Correct Answer is D

Explanation

Answer: (D) Encourage the client to discuss the problem with other clients

Rationale:

A) Call housekeeping to clean up the lounge: While involving housekeeping might address the immediate issue, it does not empower the client or involve them in the community aspect of the unit. The goal in a mental health setting is to encourage clients to take an active role in resolving communal issues, fostering responsibility, and promoting interpersonal communication.

B) Promise the client that the issue will be discussed at the next community meeting: While addressing the issue in a community meeting is appropriate, simply promising to bring it up without involving the client may not address the immediate concern or empower the client to take an active role. The client might feel dismissed if their concerns are not immediately acknowledged or acted upon.

C) Help the client clean up the dayroom: Assisting the client in cleaning the lounge may resolve the mess temporarily but does not address the underlying issue of other clients leaving trash. It is more beneficial for the client to engage in communication with their peers to foster a sense of community and mutual respect.

D) Encourage the client to discuss the problem with other clients: Encouraging the client to communicate directly with their peers is a therapeutic approach that fosters assertiveness and problem-solving skills. It allows the client to express their concerns and take responsibility for addressing issues within the community, which is beneficial in their mental health recovery process.

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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

A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding?

Correct Answer is C

Explanation

A nurse in an acute care mental health unit is speaking with a client who reports that other clients leave trash in the lounge. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is planning an Interview for a newly admitted client and plans to Include the client's family members. Which of the following methods should the nurse use to determine who to include in the interview?

A client who has rheumatoid arthritis shows the nurse at her provider's office her magnetic copper bracelet and says that it helps alleviate her pain when she wears it. Which of the following responses should the nurse make?

A nurse is caring for a client who reports a state of Increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?

A nurse observes that a client is sitting alone in her room crying. As the nurse approaches, she states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses is appropriate for the nurse?

A nurse is helping a client relieve stress through cognitive reframing. Which of the following actions by the client demonstrates effective use of cognitive reframing?

A nurse on an inpatient mental health unit is assisting with the admission of a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following assessments should the nurse make first?

A nurse is caring for a client who escapes anxiety-causing thoughts by ignoring their existence. The nurse should recognize this behavior as which of the following defense mechanisms?

The nurse is caring for a client who has been admitted Involuntarily for psychiatric treatment. Which of the following Information about involuntary commitment should the nurse provide the client's family?