A nurse on a mental health unit enters the day room and observes a client hit another client. Which of the following statements should the nurse make?
"I'm taking away your TV privileges and putting you in seclusion."
"Hitting others is unacceptable behavior."
"Your behavior will disappoint your provider."
"Why did you hit another client?"
The Correct Answer is B
Choice A reason:
Taking away TV privileges and placing the client in seclusion could be perceived as punitive rather than therapeutic. It may escalate the situation and does not address the immediate need to ensure safety and de-escalate the aggression.
Choice B reason:
Stating that hitting others is unacceptable is a clear and direct way to address the behavior. It sets a firm boundary and communicates the expectations for behavior within the unit, which is essential in managing aggressive situation.
Choice C reason:
Saying that the behavior will disappoint the provider personalizes the issue and may not be effective in the moment. The focus should be on the immediate safety of all clients and the unacceptability of the behavior, rather than on the potential emotional response of the provider.
Choice D reason:
Asking why the client hit another client immediately after the incident may not be productive and could lead to further justification of the behavior or additional aggression. It's important to first address the behavior and ensure safety before exploring the reasons behind it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
While interviewing is a component of the nursing process, specifically during the assessment phase, describing the nursing process solely as a method for interviewing is incomplete. The nursing process encompasses much more, including diagnosis, planning, implementation, and evaluation.
Choice B Reason:
This statement accurately reflects the purpose of the nursing process. It is a systematic method used by nurses to assist clients in adapting to stressors, whether they are physical, psychological, or social. The process involves assessing the client's needs, diagnosing issues, planning and implementing interventions, and evaluating the outcomes.
Choice C Reason:
The nursing process does play a role in minimizing allegations of negligence by providing a structured approach to care, but this is not its primary purpose. The main goal is to deliver individualized and effective care to clients, not just to protect against legal issues.
Choice D Reason:
Supporting a psychiatric diagnosis is part of the nursing process, but the statement is too narrow to describe the overall purpose. The nursing process is used to plan and provide personalized care, which goes beyond just supporting a diagnosis.
Correct Answer is D
Explanation
Choice A Reason:
An adventitious crisis is not applicable here. This type of crisis is usually a result of a natural or man-made disaster, war, or major accident, which is not the case with the client's situation.
Choice B Reason:
Maturational crises are associated with life transitions or developmental stages, such as retirement or menopause. While the client is older, the crisis is not due to a normal life transition but rather an unexpected event.
Choice C Reason:
Developmental crises occur as a person moves through the stages of life. The client's crisis does not stem from a developmental issue but from an external event that has disrupted their life.
Choice D Reason:
Situational crises arise from external sources that an individual may face throughout life, such as the death of a loved one, loss of a job, or severe illness. The client's inability to cope with the sudden death of their spouse is a situational crisis.
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