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
Projection is a defense mechanism where an individual attributes their own thoughts, feelings, or impulses onto someone else. In this case, the client is attributing the cause of their drug use to their parents not allowing them to get a tattoo. By projecting their desire for a tattoo onto their parents' decision, the client is displacing their own feelings onto an external factor.
Incorrect:
A. Suppression: Suppression involves consciously pushing away or blocking unwanted thoughts, feelings, or impulses. The client's statement does not indicate an attempt to suppress any thoughts or emotions related to their drug use; instead, they are openly discussing the reason for their substance use.
B. Intellectualization: Intellectualization involves using excessive reasoning or logic to avoid acknowledging or experiencing associated emotions. The client's statement does not reflect intellectualization, as they are not overly relying on intellectual processes or attempting to detach themselves from the emotional aspects of their behavior.
C. Dissociation: Dissociation involves a temporary disconnection from thoughts, feelings, or memories to avoid emotional distress. The client's statement does not demonstrate dissociation, as they are connecting their drug use to a specific event and cause.
Correct Answer is D
Explanation
The response "You are feeling drawn in two different directions" acknowledges the daughter's conflicting feelings and validates her emotions. It demonstrates empathy and understanding of her situation. It can help the daughter feel heard and supported and opens up an opportunity for further conversation about her concerns and possible solutions.
The other options are less appropriate:
A- "Don't worry. We'll take good care of your father while you are gone." While this response reassures the daughter about her father's care, it does not address her emotional conflict or provide support for her own needs and concerns.
B- "Perhaps you could stay here and just call your family to see how they are doing." This response minimizes the daughter's situation and does not fully acknowledge her need to be with her own family. It may overlook the emotional strain and responsibilities she may have outside of the hospital.
C-"There's nothing you can do here. You should go home to your family." This response dismisses the daughter's feelings and implies that her presence is not necessary or valuable. It does not consider her desire to support her father or the importance of maintaining a connection with him during his hospitalization.
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