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 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.

A. "Clients who are involuntarily admitted have the right to informed consent." B. "Clients should be given medications even if they refuse them." C. "The laws regarding restraints are different for clients who are admitted involuntarily." D. "Clients who are admitted involuntarily can be hospitalized for as long as the provider deems necessary."

Correct Answer is C

Explanation

Informed consent typically pertains to medical treatments and interventions. Involuntary admissions involve clients who are admitted due to safety concerns, and they may not have the capacity to provide informed consent in the same way as clients in voluntary admissions.

B) "Clients should be given medications even if they refuse them."

While there might be cases where medications are administered to clients who are involuntarily admitted, this statement is not complete. Administration of medications to clients against their will usually involves a process that considers the individual's best interests and relevant legal requirements.

C) "The laws regarding restraints are different for clients who are admitted involuntarily."

Explanation:

Involuntary admissions involve individuals who are admitted to a mental health facility against their will due to the potential risk they pose to themselves or others. The laws regarding their care and rights may differ from those for voluntary admissions. One aspect where there might be differences is the use of restraints and seclusion.

Clients who are admitted involuntarily have specific legal rights and protections, and these rights vary depending on the jurisdiction and specific mental health laws in place. In many cases, there are regulations that govern the use of restraints and seclusion for clients who are involuntarily admitted. These regulations are in place to ensure the safety and dignity of the individuals while balancing the need for appropriate intervention.

D) "Clients who are admitted involuntarily can be hospitalized for as long as the provider deems necessary."

Involuntary admissions have a legal framework that includes specific criteria for continuing the hospitalization. Clients who are admitted involuntarily cannot be held indefinitely without a proper evaluation and review of their condition and treatment plan.

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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

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 manager on a mental health unit is discussing involuntary admissions during a staff meeting. Which of the following statements should the manager include in the discussion?

Correct Answer is C

Explanation

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