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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer: (D) Suppression
Rationale:
A) Dissociation: Dissociation involves a disconnection from reality or the separation of thoughts, memories, or identity from conscious awareness. In this scenario, the client is not displaying any signs of disconnecting from reality or avoiding awareness of the situation through dissociation, making this defense mechanism unlikely.
B) Projection: Projection occurs when an individual attributes their own unacceptable thoughts or feelings to others. The client in this situation is not blaming others or attributing their actions to someone else, so projection is not the defense mechanism being demonstrated here.
C) Intellectualization: Intellectualization involves using reasoning or logic to avoid emotional stress or anxiety. While the client does mention logical-sounding plans about things working out next week, their overall response does not primarily reflect an avoidance of emotion through reasoning, so intellectualization is not the correct choice.
D) Suppression: Suppression is the conscious decision to delay paying attention to an emotion or need in order to cope with the present situation. The client acknowledges the stress of being fired but chooses to push aside their distress by stating that "everything will work out somehow next week," indicating they are consciously choosing to set aside their anxiety for the time being. This aligns with the concept of suppression.
Correct Answer is B
Explanation
Determining if the client has thoughts of self-harm: This is the priority action for the nurse in this situation. Assessing the client's risk of self-harm or suicide is crucial to determine the level of immediate intervention required. It helps identify the severity of the crisis and enables the nurse to implement appropriate measures to ensure the client's safety.
In the context of a client with generalized anxiety disorder who is exhibiting signs of distress and seeking to be taken care of, it is essential to assess for suicidal ideation or intent. Clients with mental health disorders, especially when experiencing high levels of stress, may be at an increased risk of self-harm or suicide. Therefore, it is vital for the nurse to prioritize the assessment of the client's safety and risk of self-harm in order to provide appropriate care and interventions.
Incorrect:
A- Asking the client to identify the cause of the crisis: While it is important to gather information about the cause of the crisis to understand the client's situation, it is not the nurse's priority at this moment. Assessing the client's safety and immediate risk of self-harm takes precedence.
C- Identifying if friends or family are available to help: While social support from friends and family can be valuable in managing a crisis, it is not the nurse's priority in this situation. The immediate concern is to assess the client's safety and risk of self-harm.
D-Identifying the client's coping skills: Assessing the client's coping skills is an important aspect of the overall assessment process, but it is not the priority at this moment. The nurse needs to first ensure the client's safety and address any immediate risks.
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