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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Maintain eye contact until the behavior stops. Maintaining eye contact can be perceived as confrontational and may escalate the situation.
B. Tell the client her behavior is disappointing. Telling the client her behavior is disappointing is judgmental and not therapeutic.
C. Punish the client for the behavior. Punishing the client is not appropriate or therapeutic.
D. Leave the client's room. Leaving the room can help de-escalate the situation by removing the immediate trigger for the client's anger.

A. Increased body temperature B. Cardiac dysrhythmias C. Hypotension D. Bradycardia

Correct Answer is B

Explanation

A. Increased body temperature: Alcohol consumption typically causes vasodilation, which can lead to a decrease in body temperature, not an increase.
B. Cardiac dysrhythmias: Large amounts of alcohol can affect the heart's electrical system, leading to cardiac dysrhythmias.
C. Hypotension: Alcohol is a vasodilator, which can lead to a drop in blood pressure (hypotension).
D. Bradycardia: Alcohol typically causes tachycardia (increased heart rate), not bradycardia (decreased heart rate).

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is B

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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?