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 C
Explanation
This response is an appropriate nursing response in this situation. It acknowledges the client's need for assistance with grocery shopping while also recognizing that shopping and personal errands are not within the nurse's job description. By suggesting to explore other resources, the nurse can help the client find alternative solutions to meet their needs. This response demonstrates a willingness to support the client and collaborate on finding appropriate assistance, while also maintaining professional boundaries and responsibilities.
A. "I won't be able to shop for you today because I have to get home to my family." This response is inappropriate because it focuses on the nurse's personal circumstances and may come across as dismissive of the client's request for help. It does not address the client's needs or offer any alternative solutions.
B. "What I think you should do is wait for the days when you feel better and do your grocery shopping then." This response is dismissive of the client's current situation and does not offer any practical assistance or support. It implies that the client should simply wait for their condition to improve without addressing their immediate needs.
D. "I would be happy to do whatever I can to help you." While this response may initially seem supportive, it is inappropriate because shopping and performing personal errands for the client are not within the nurse's job description. It is important for the nurse to establish professional boundaries and adhere to the responsibilities outlined in their job description.
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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