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 B
Explanation
A. "Disulfiram will prevent my cravings for alcohol." Disulfiram (Antabuse) is a medication that causes a severe adverse reaction when alcohol is consumed, acting as a deterrent. It does not prevent cravings for alcohol.
B. “One should expect hand tremors to start less than 24 hours after I stop drinking." Hand tremors are one of the early signs of alcohol withdrawal and typically begin within 6 to 12 hours after the last drink.
C. "Withdrawal symptoms should last about 5 to 7 days once they begin." Alcohol withdrawal symptoms usually peak within 24 to 48 hours and can last up to 72 hours, though some symptoms may persist longer in severe cases.
D. "It is important that I take Vitamin C to prevent liver cirrhosis or other liver damage." While vitamin supplementation is important for overall health, taking Vitamin C does not specifically prevent liver cirrhosis or other liver damage.
Correct Answer is B
Explanation
A. Facilitate time alone for the client. Allowing time alone is not appropriate for a suicidal client as it increases the risk of self-harm.
B. Make a no self-harm contract. A no self-harm contract can be part of a suicide prevention plan, where the client agrees to not harm themselves and to seek help if they feel the urge to do so.
C. Administer antianxiety medication: While medication can help with anxiety, it is not a primary intervention for immediate suicide prevention.
D. Prevent family/friend visitation for 48 hours: Preventing visitation can increase feelings of isolation and is not an appropriate intervention for suicide prevention.
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