A nurse on a mental health unit notices that a client is becoming increasingly agitated and throws a table when he is unable to select the television (TV) channel. Which of the following should be a priority action by the nurse?

Attempt to talk the client down.

Administer a PRN antianxiety medication.

Place the client in a monitored seclusion room until he is calm.

Restrain the client to prevent injury to himself or others.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Attempting to talk the client down is the priority action in this situation. Agitation can escalate to aggression or violence if not addressed appropriately. Engaging in therapeutic communication can help de-escalate the client's agitation, express understanding, and potentially find out the underlying cause of their distress. This approach prioritizes a non-pharmacological intervention.

Choice B rationale:

Administer a PRN antianxiety medication. While medication might be a consideration for managing agitation, it's generally not the first action to take. Non-pharmacological interventions, like therapeutic communication, should be attempted first to minimize the reliance on medications to manage behaviors.

Choice C rationale:

Place the client in a monitored seclusion room until he is calm. Placing a client in seclusion should be a last resort and should only be done when there's an immediate risk of harm to the client or others. In this scenario, the client's agitation doesn't seem to present an imminent danger, so seclusion would be an excessive and restrictive intervention.

Choice D rationale:

Restrain the client to prevent injury to himself or others. Restraint should be an absolute last resort and only used when there's an imminent risk of harm that cannot be managed in any other way. Restraint can escalate agitation and trauma for the client, as well as pose legal and ethical concerns. Therefore, it should only be used when all other options have been exhausted and safety is a critical concern.

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Correct Answer is A

Explanation

Choice A rationale:

Similar to the explanation in , this statement requires intervention. It reflects a judgmental and prescriptive approach, which is not conducive to a therapeutic conversation. It implies that the nurse knows what the client should do, undermining the client's autonomy and self-discovery process.

Choice B rationale:

Recognizing that relationship difficulties are stressful and require effort to resolve is a valid and supportive statement. It acknowledges the challenges the client is facing and does not impose a specific solution.

Choice C rationale:

Suggesting the development of a communication plan is a proactive and therapeutic response. It empowers the client to work collaboratively toward improving their marital situation.

Choice D rationale:

Encouraging the client to share more about their concerns promotes open communication and allows the nurse to better understand the client's perspective. This response is client-centered and supportive.

A. The partner has placed locks at the top of the doors leading to the outside. B. The partner redirects the client when the client is frustrated. C. The partner has hired a house cleaner. D. The partner has lost 25 lbs in the past 3 months.

Correct Answer is D

Explanation

The correct answer is choice D: "The partner has lost 25 lbs in the past 3 months."

Choice D rationale:

This choice is the correct answer because significant weight loss in a caregiver, such as the partner of a client with Alzheimer's disease, is indicative of caregiver role strain. Caregiver role strain refers to the physical, emotional, and psychological stress experienced by caregivers due to the demands of providing care for a loved one. Weight loss in this context suggests that the partner's own health and well-being are being compromised due to the caregiving responsibilities.

Choice A rationale:

This choice might be related to safety concerns and trying to prevent the client from wandering, but it does not directly indicate caregiver role strain. Placing locks at the top of doors is a common safety measure to prevent clients with Alzheimer's disease from wandering and getting lost.

Choice B rationale:

This choice is actually a positive observation. Redirecting a frustrated client is a helpful and appropriate caregiving strategy. It indicates that the partner is actively engaged in managing the client's behavior and emotions, which is not a sign of caregiver role strain.

Choice C rationale:

Hiring a house cleaner is a practical decision and could be a sign of the partner's effort to manage their caregiving responsibilities more effectively. While it might imply a certain level of stress, it doesn't directly point to caregiver role strain as much as the significant weight loss does.

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A nurse on a mental health unit notices that a client is becoming increasingly agitated and throws a table when he is unable to select the television (TV) channel. Which of the following should be a priority action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is sharing information regarding concerns about their marriage. The client states "My spouse and I argue most times." Which of the following statements by the nurse requires intervention by the charge nurse?

Correct Answer is A

Explanation

A home health nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?

Correct Answer is D

Explanation

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