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 C
Explanation
Choice A reason - "Don't worry. We'll take good care of your parent while you are gone.":
This statement is meant to reassure the son that his parent will be well-cared for in his absence, which is an important concern for family members of patients. However, it does not provide any immediate comfort or solution to his dilemma of needing to be in two places at once.
Choice B reason - "You are feeling drawn in two separate directions.":
By acknowledging the son's feelings, the nurse is showing understanding and empathy. Recognizing the emotional conflict is a key step in providing emotional support, but the response stops short of offering actionable advice or comfort.
Choice C reason - "Perhaps you could call your children to see how they are doing.":
This suggestion is helpful because it gives the son a way to be involved with his children's well-being without having to leave the hospital. It's a compromise that addresses both of his concerns and can provide him with some peace of mind.
Choice D reason - "There's nothing you can do here. You should go home to your children.":
While this might be a practical suggestion, it fails to consider the son's emotional state and his need to support his hospitalized parent. It could make him feel guilty or negligent for considering leaving, even if it's to attend to his children.
Correct Answer is A
Explanation
Choice A Reason:
This response may invalidate the client's experience and can be perceived as dismissive of the client's delusional thoughts. It does not acknowledge the client's current reality or provide any therapeutic communication. An intervention is required to guide the nurse in offering a more empathetic and validating response.
Choice B Reason:
Asking the client to clarify what they mean encourages communication and shows a willingness to understand the client's perspective. It is a therapeutic approach that can help the nurse gain insight into the client's thoughts and provide appropriate support.
Choice C Reason:
This response could potentially validate the client's delusional thinking by engaging in the content of the delusion. It might lead to further discussion about the delusion rather than redirecting the client to reality, which could be counterproductive.
Choice D Reason:
Expressing empathy by acknowledging that the client's feelings must be frightening is a therapeutic response. It validates the client's emotions without confirming the delusional content and can help the client feel understood and supported.
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