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 D

Explanation

The appropriate response by the nurse in this situation is to set clear boundaries and remove themselves from the situation. By stating, "I'm going to leave now and I'll return in one hour to spend time with you then," the nurse establishes that the inappropriate behavior is not acceptable and that they will return later to continue providing care within professional boundaries.

A- "I'm sure that you don't intend to behave this way, so I'm going to ignore this behavior" is not an appropriate response. Ignoring the behavior can potentially enable or encourage further inappropriate advances, and it does not address the issue directly.

B- "I'm curious as to why you are behaving this way. Can you please explain it to me?" places the responsibility on the client to explain their behavior, which is not appropriate or necessary in this situation. It may also encourage further discussion of the inappropriate behavior.

C- "I'm very flattered, but I am married and cannot engage in this behavior" personalizes the situation and may give the wrong impression that the nurse's marital status is the reason for rejecting the advances. It is important to maintain professional boundaries and not involve personal factors in the response.

A. "It is economical, since one staff member can treat many clients at once." B. "It provides a forum to reinforce client teaching regarding medication administration." C. "It establishes a situation where the client can relate to others and share perceptions." D. "It enables clients to see that other individuals have mental health issues."

Correct Answer is C

Explanation

Group therapy is a valuable treatment method in mental health settings that offers several benefits. The statement "It establishes a situation where the client can relate to others and share perceptions" highlights one of the primary advantages of group therapy. In a group therapy setting, individuals with similar mental health issues come together to share their experiences, challenges, and perspectives. This process allows clients to realize that they are not alone in their struggles and fosters a sense of belonging and understanding. It can provide comfort, validation, and support as participants gain insight into their own thoughts and feelings through interactions with others.

Incorrect:

A. "It is economical since one staff member can treat many clients at once." While group therapy can be cost-effective in terms of staff resources, its primary goal is not solely based on economic considerations. The focus is on providing a therapeutic environment that promotes growth, support, and interpersonal learning for participants.

B. "It provides a forum to reinforce client teaching regarding medication administration." Although group therapy sessions may occasionally touch upon topics related to medication management, the main purpose of group therapy is not to provide medication education or reinforcement. Individual counseling or psychoeducation sessions are typically more appropriate for that specific purpose.

D. "It enables clients to see that other individuals have mental health issues." While it is true that group therapy allows individuals to witness the experiences of others with mental health issues, the purpose is not limited to simply observing that others have similar struggles. The primary goal is to create a safe space for participants to actively engage, share, and explore their own experiences in a supportive and therapeutic group setting. The focus is on personal growth, insight, and development.

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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 client who begins to make sexual advances towards him. Which of the following is an appropriate statement by the nurse?

Correct Answer is D

Explanation

A nurse on a mental health unit is assisting with several group therapy sessions. The nurse should include which of the following Information about using group therapy as a treatment method?

Correct Answer is C

Explanation

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