A spouse brings a client to an extremely busy emergency department due to erratic behavior and expressions of despair.

When the triage registered nurse asks if the client feels suicidal now, the client shrugs their shoulders. Based on these findings, which nursing responsibility is the practical nurse expected to be assigned?

Ask the client to make a verbal contract to not harm self.

Return the client to the waiting room with the spouse.

Document that the client is not currently suicidal.

Place the client in an inside hallway with one-on-one observation.

Answer and Explanation

The Correct Answer is D

Choice A rationale
While making a verbal contract not to harm oneself can be a part of suicide prevention strategies, it is not the immediate responsibility in this scenario. The client’s erratic behavior and expressions of despair indicate a high level of distress and potential risk for self-harm.
Choice B rationale
Returning the client to the waiting room with the spouse does not ensure the client’s safety. The spouse may not be equipped to manage the client’s current emotional state, and the busy environment of the waiting room may exacerbate the client’s distress.
Choice C rationale
Documenting that the client is not currently suicidal is not appropriate in this situation. The client’s non-verbal cues (shrugging their shoulders when asked about suicidal thoughts) may indicate ambivalence or uncertainty about their intent to harm themselves.
Choice D rationale
Placing the client in an inside hallway with one-on-one observation is the most appropriate action. This ensures the client’s safety, allows for continuous monitoring of the client’s condition, and provides an opportunity for further assessment and intervention.

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Correct Answer is C

Explanation

Choice C rationale
Assisting the patient in identifying a thought that triggers anger, evaluating the validity of the belief, and replacing it with reality-based thinking is an effective nursing intervention to help an angry patient manage their anger without resorting to violence. This approach is based on cognitive behavioral therapy (CBT), a type of psychotherapy that can help people learn to identify and change destructive thought patterns that have a negative influence on behavior and emotions.
Choice A rationale
While medication can be part of a comprehensive treatment plan for individuals struggling with anger management, it is not the first-line intervention. Medication should be considered if the anger is part of a larger mental health disorder, such as bipolar disorder or intermittent explosive disorder, and should be administered under the guidance of a healthcare provider.
Choice B rationale
Negative reinforcement such as restraint or seclusion can escalate the situation and is not considered a best practice for managing anger. It should only be used as a last resort when the patient poses a risk to themselves or others.
Choice D rationale
Aversive conditioning, such as snapping a rubber band on the wrist, is a type of behavioral therapy that can be used to help a person reduce or eliminate unwanted behaviors. However, it is not the most effective strategy for managing anger and can potentially lead to self-harm.

A. “You want to go home to prepare your husband’s dinner?” B. “You must come away from the door.”. C. “Your husband gets angry if you don’t have dinner ready on time?” D. “You have been a widow for many years.”.

Correct Answer is A

Explanation

Validation therapy is a method of therapeutic communication which can be used to connect with someone who has moderate to late-stage dementia. It places more emphasis on the emotional aspect of a conversation and less on the factual content, thereby imparting respect to the person, their feelings, and their beliefs. In this scenario, the nurse should validate the patient’s feelings and emotions by saying, “You want to go home to prepare your husband’s dinner?”

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is an effective nursing intervention to help an angry patient manage their anger without resorting to violence?

Correct Answer is C

Explanation

A patient with cognitive impairment, who has been a widow for 30 years, is desperately trying to leave the facility, stating, “I have to go home to cook dinner before my husband gets home from work.”. How should the nurse intervene using validation therapy?

Correct Answer is A

Explanation

A patient is pacing the hall near the nurse’s station, swearing loudly. What would be an appropriate initial intervention for the nurse?

Haldol 2mg IM stat has been ordered for the agitated client. Haldol is available in 5mg/ml. How many ml’s will you administer?

In communicating with the psychiatric patient, which nurse responses could obstruct effective communication with a client? (Select all that apply)

A nurse is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors for suicide? (Select all that apply).

During a therapy session, which statement made by the nurse indicates a need for further training in effective therapeutic communication techniques?

The home health aide reports to the practical nurse that the client has been trying to give away possessions. When the nurse asks the client about this behavior, the client says, “With my spouse dead, there’s no reason for me to go on.”. What is the best priority response by the nurse?

What expected outcomes should the nurse document for a client diagnosed with a depressive disorder? (Select all that apply)

During the assessment of a mental health client, it is crucial for the nurse to thoroughly check for symptoms of depression. Which symptom is indicative of Depression?