A nurse on a mental health unit is caring for a newly admitted client.
The nurse is continuing to care for the client. Which of the following actions should the nurse take?(Select All that Apply.)
Gently place a hand on the client's arm during conversation.
Employ active listening skills when communicating with the client.
Administer an anxiolytic medication to the client.
Explain the expected behavioral limits to the client.
Assist the client to identify the source of anger.
Correct Answer : B,C,D,E
A. Gently place a hand on the client's arm during conversation
Avoid touching an anxious or potentially aggressive client-may escalate agitation.
B. Employ active listening skills
Validates feelings and promotes therapeutic communication.
C. Administer an anxiolytic medication
Client is showing signs of withdrawal and agitation-medication may be indicated.
D. Explain behavioral limits
Setting limits provides structure and promotes safety.
E. Assist in identifying source of anger
Supports emotional processing and de-escalation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Try to be patient..."
Encouraging self-compassion is therapeutic and promotes realistic recovery expectations.
B. "You could try to stop all at once..."
Not safe-sudden cessation can lead to withdrawal symptoms.
C. "You should probably stop socializing..."
Social isolation is not encouraged in recovery.
D. "Maybe someone at your homeless shelter..."
Assumes client’s housing status and may be judgmental or stereotyping.
Correct Answer is B
Explanation
A. Increased blood pressure
BP typically decreases in hypovolemia due to reduced circulating volume.
B. Weak pulse
A weak, thready pulse is common due to reduced perfusion and cardiac output.
C. Decreased heart rate
HR usually increases to compensate for low volume.
D. Dyspnea
Not a specific or early sign of hypovolemia; more common in fluid overload.
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