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.

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Correct Answer is C

Explanation

A. Discuss the problem in a community meeting with the other clients on the unit present.

While open communication and community meetings can be valuable in certain situations, discussing a client's disruptive behavior in front of others may breach their privacy and dignity. It's important to address such matters privately and respectfully.

B. Escort the client to her room each time the nurse observes the client socializing with other clients.

This action might be seen as overly punitive and restrictive. Isolating the client based on their behavior without addressing the underlying issues doesn't promote a therapeutic approach to the situation.

C. Talk to the client and identify the specific limits that are required of the client's behavior.

This is the correct option. Talking to the client directly allows the nurse to address the behavior, express expectations, and set clear boundaries. This approach promotes open communication and gives the client a chance to understand how their actions are affecting others.

D. Tell the other clients to ignore the client's lies.

While it's important to encourage other clients to manage their reactions to disruptive behavior, simply telling them to ignore lies might not address the root cause of the issue. The nurse should aim to address the behavior itself and create an environment where all clients feel respected and safe.

A. Explain the client that the behavior was unacceptable. B. Explore the truth of the client's statements. C. Set behavioral limits for the client. D. Establish a client relationship

Correct Answer is C

Explanation

A. Explain to the client that the behavior was unacceptable: While addressing the behavior is important, it is more effective to first establish clear limits and boundaries to prevent further incidents.

B. Explore the truth of the client’s statements: This step involves assessing the client's statements and understanding their perspective, which is important but can be done after setting behavioral limits.

C. Set behavioral limits for the client: Establishing clear behavioral limits is crucial for maintaining safety and order in the psychiatric unit. It helps ensure that the client understands what is expected of them and the consequences of unacceptable behavior. This is particularly important if the client has exhibited aggressive behavior, as it helps prevent further incidents and maintains a safe environment for everyone.

D. Establish a client relationship: Building a therapeutic relationship is essential for effective treatment, but it should be done in the context of a safe environment where clear behavioral expectations have already been established.

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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

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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