A nurse is sitting in the day room at an acute care mental health facility with a group of clients who are watching television. Suddenly one of the client's jumps up screaming and runs out of the room. Which of the following actions should the nurse take?
Ignore the incident since it is an attention-seeking behavior.
Stay with the group and ask another client to go and check on the situation.
Follow the client to determine the cause of the behavior.
Ask the group what they think about the client's behavior.
The Correct Answer is C
A. Ignore the incident since it is an attention-seeking behavior: Ignoring the incident is not appropriate because the client may be in distress or at risk of harm.
B. Stay with the group and ask another client to go and check on the situation: Asking another client to check on the situation is not appropriate, as it is the nurse's responsibility to ensure the safety of all clients.
C. Follow the client to determine the cause of the behavior: Following the client allows the nurse to assess and intervene appropriately to ensure the client's safety and address the cause of the behavior.
D. Ask the group what they think about the client's behavior: Discussing the behavior with the group is not appropriate in an emergency situation and does not address the immediate needs of the distressed client.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Share findings with other caregivers. Sharing information with other caregivers is important for continuity of care but is not a direct intervention for managing anger and aggression.
B. Set limits on client behaviors. Setting limits on behavior is necessary, but it should be done within the context of a trusting relationship.
C. Establish and maintain a trusting relationship: Building a trusting relationship is the foundation for effective therapeutic interventions, including managing anger and aggression.
D. Offer prn medication: Offering prn medication can help manage symptoms but should be part of a broader therapeutic strategy.
Correct Answer is D
Explanation
A. Sexual abuse: While sexual abuse can cause physical and emotional symptoms, the combination of unexplained injuries and fussiness/irritability is more suggestive of physical trauma.
B. Neglect: Neglect involves failure to provide for the child's basic needs, which can lead to developmental issues, but is less likely to cause unexplained injuries.
C. Munchausen syndrome by proxy: Munchausen syndrome by proxy involves a caregiver fabricating or inducing illness in a child for attention. It can cause unexplained injuries, but the focus is more on medical symptoms.
D. Shaken baby syndrome: Shaken baby syndrome results from violently shaking an infant, leading to physical injuries, irritability, and fussiness. It fits the description of unexplained injuries and behavioral changes.
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