A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?

Have a staff member escort the client to her room.

Allow the client to pace alone until physically tired.

Instruct the client to sit down and stop pacing.

Walk with the client at a gradually slower pace.

Answer and Explanation

The Correct Answer is D

A) Have a staff member escort the client to her room:

Having a staff member escort the client to her room might be perceived as restrictive and could potentially escalate the client's anxiety. It's important to give the client some autonomy and not force them into isolation.

B) Allow the client to pace alone until physically tired:

While allowing the client to pace alone might seem like a non-intrusive option, it lacks the therapeutic engagement that can help the client feel supported and understood. It's important for the nurse to actively engage with the client to establish a therapeutic relationship.

C) Instruct the client to sit down and stop pacing:

Instructing the client to stop pacing could potentially increase their agitation and anxiety. Forcing the client to sit down against their wishes might lead to resistance and hinder the development of trust between the nurse and the client.

D) Walk with the client at a gradually slower pace:

This is the correct answer. Walking with the client at a gradually slower pace is a therapeutic approach that allows the nurse to build rapport, provide support, and help the client regulate their emotions. It respects the client's need for movement while also addressing their emotional state.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. "I can see that you trust me, but you should share those feelings with your psychiatrist, not me."

While encouraging the client to discuss their feelings with a mental health professional is important, this response does not address the immediate safety concern presented by the client's intent to harm others.

B. "I will not violate our nurse-client relationship. The information we discuss will remain confidential between us."

This response is inappropriate because it implies that the nurse will keep the information confidential, even though the client's statement raises concerns about the safety of others.

C. "Because you are a minor, I have to share any information that I feel is important with your parents."

While parents may have the right to be informed about their minor child's well-being, this situation goes beyond parental involvement. The nature of the threat requires immediate intervention from appropriate professionals and authorities.

"D. I cannot promise that. I must share this information with other members of the team who are responsible for planning your care."

Explanation: The client's statement about having a desire to harm others, especially classmates and a school teacher, raises significant concerns about the safety and well-being of not only the client but also the potential victims. In cases where the client poses a risk of harm to themselves or others, the nurse has a duty to breach confidentiality to ensure the safety of all involved parties. This response conveys the nurse's ethical obligation to involve other members of the treatment team and appropriate authorities to address the potential threat.

A. Discuss self-defense techniques with the client. B. Give the client a bed bath prior to physical examination. C. Inform the client photographs of injuries are required for a police report. D. Ask the client to describe the situation.

Correct Answer is D

Explanation

A. Discuss self-defense techniques with the client: Incorrect

While self-defense techniques can be useful information, discussing them immediately after a traumatic event like sexual assault may not be appropriate. The client's immediate needs for emotional support, medical evaluation, and safety are more pressing.

B. Give the client a bed bath prior to physical examination: Incorrect

In cases of sexual assault, preserving evidence is important for legal purposes and for the client's well-being. Providing a bed bath could potentially compromise evidence and hinder a thorough examination by healthcare professionals.

C. Inform the client photographs of injuries are required for a police report: Correct

Preserving evidence is crucial in cases of sexual assault, especially if the client intends to involve law enforcement. Informing the client about the importance of photographs for a police report is appropriate and can contribute to a potential legal investigation.

D. Ask the client to describe the situation: Correct

It's important to encourage the client to share their experience, but it should be done in a sensitive and supportive manner. Gathering information about the situation can help the healthcare team understand the scope of the assault, provide appropriate medical care, and offer necessary emotional support.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an adolescent who has a history of violent behavior and has asked the nurse to keep confidential information about he desire to kill several classmates and a school teacher. Which of the following responses by the nurse is appropriate to give?

Correct Answer is D

Explanation

A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

A nurse in a psychiatric unit is admitting a client who attacked a neighbor. The nurse should know that the client can be kept in the hospital after the 72-hr hold is ever for which of the following conditions?

A nurse is preparing to administer haloperidol 75 mg IM per week. Available is haloperidol decanoate 100mg/ml for injection. How many ml should the nurse administer per dose? (Round the answer to the nearest hundredth. Use a leading zero if it applies.

A nurse assessing a client who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect?

A nurse is providing care for a client who has anorexia nervosa. Which of the following nursing interventions should the nurse take?

An acute mental health whit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania?

A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse, "I should have died because I am totally worthless." Which of the following responses should the nurse make?

A nurse is teaching a newly-admitted client about the possible physical effects of alcohol withdrawal. Which of the following manifestation should the nurse include in the reaching? (Select all that apply.)