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 A

Explanation

The response "I will assist you in getting out of bed and getting dressed" demonstrates a supportive and therapeutic approach. It acknowledges the client's current state and offers assistance to engage in self-care activities. By providing support and actively participating in the client's care, the nurse can promote motivation, engagement, and a sense of empowerment.

The response "You can remain in bed until you feel well enough to join the milieu" may enable the client's depressive behaviors and reinforce the avoidance of activities. It does not encourage participation or provide support for the client to engage in therapeutic activities.

The response "The unit rules state that clients may not remain in bed" focuses on enforcing rules rather than addressing the client's underlying emotional state and needs. It may increase resistance and hinder the therapeutic relationship.

The response "If you don't participate in your care, you will not get better" may be perceived as blaming or judgmental. It may increase the client's guilt or sense of failure and does not provide practical support or encouragement.

A. Projection B. Dissociation C. Repression D. Sublimation

Correct Answer is B

Explanation

Dissociation is a defense mechanism in which a person disconnects from their thoughts, feelings, memories, or sense of identity as a way to cope with overwhelming or traumatic experiences. In this case, the client's inability to remember anything that happened after seeing the suspects in the stabbing is a form of dissociation. It is a way for the client to psychologically distance themselves from the traumatic event and protect themselves from the emotional distress associated with it.

A- Projection is a defense mechanism where an individual attributes their own undesirable thoughts, feelings, or impulses onto someone else.

C- Repression is a defense mechanism where disturbing or unacceptable thoughts, memories, or feelings are pushed into the unconscious mind.

D- Sublimation is a defense mechanism where unacceptable impulses or emotions are redirected into socially acceptable activities.

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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 caring for a newly admitted female client who has depression and refuses to get out of bed, dress, or participate in group therapy. Which of the following is an appropriate nursing response?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

A nurse is caring for a client with whom he has developed a therapeutic relationship and who will be discharged later in the day. The client thanks the nurse for his help during the hospitalization. Which of the following responses should the nurse make?

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