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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Deceitfulness: Deceitfulness is more associated with antisocial personality disorder rather than impulse control disorders.
B. Aggressive conduct: Aggressive conduct is associated with conduct disorder, not specifically with impulse control disorders.
C. Serious rule violations: Serious rule violations are characteristic of conduct disorder.
D. Pyromania: Pyromania is an impulse control disorder characterized by the recurrent urge to set fires.
Correct Answer is D
Explanation
A. "What will you accomplish by taking your life?" This question is not therapeutic and may be perceived as judgmental or dismissive.
B. "What happened to you in the past to make you so desperate?" This question focuses on past events and may not address the immediate crisis.
C. "Why do you feel depressed enough to end your life?" This question is less direct and may not elicit a specific plan, which is crucial for assessing risk.
D. "How will you carry out your plan?" This question is direct and helps to determine if the client has a specific plan, which is a key factor in assessing the immediacy and severity of the suicide risk.
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