An angry client has just thrown a chair across the room and is racing to pick up another chair to throw. Which is the most appropriate action by the nurse?
Call for an emergency response from trained personnel.
Calmly call the client by name and encourage verbal expression of anger.
Approach the client and firmly say. "Stop. put it down."
Assist the client to use problem-solving techniques instead of aggression
The Correct Answer is A
The safety of both the client and others is the top priority in this situation. The client's aggressive behavior poses a significant risk, and immediate action is necessary. Calling for an emergency response from trained personnel, such as security or other staff members experienced in handling aggressive behavior, can help ensure the situation is properly managed and de-escalated in a safe manner.
Option B may not be appropriate in this situation, as trying to engage the client in verbal expression of anger while they are in an agitated and aggressive state can potentially escalate the situation further.
Option C is not recommended, as approaching the client in a confrontational manner may further escalate their anger and aggression.
Option D, while it may be beneficial in a different context and when the client is in a more stable state, is not appropriate when the client is actively engaged in aggressive behavior. The focus at this moment should be on ensuring the immediate safety of everyone involved.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When a client has an angry outburst and then quickly appears calmer and receptive to input from the nurse, it is important for the nurse to address the underlying cause of the outburst and explore the client's feelings and emotions. By asking, "What happened that got you so upset?", the nurse is inviting the client to express their feelings and share what triggered their anger. This can help the nurse understand the client's perspective, provide appropriate support, and potentially de-escalate any remaining tension or frustration.
The other options are inappropriate because:
A- "We will have to talk about this later." This response may make the client feel dismissed or that their feelings are not being heard or understood.
C- "You really scared me. I'm glad you are okay." While this response acknowledges the client's emotional state, it centers the focus on the nurse's feelings rather than exploring the client's perspective or emotions.
D- "Your behavior is unacceptable and will not be tolerated." This response is confrontational and judgmental, which can escalate the situation and potentially trigger further defensive reactions from the client.
Overall, a non-judgmental and empathetic approach that focuses on understanding the client's feelings and experiences is more likely to foster open communication and provide the client with a safe space to express themselves.
Correct Answer is C
Explanation
When dealing with a client who is manipulative and disruptive but not demonstrating behaviors that are a threat to self or others, it is essential for the nurse to set clear and consistent boundaries for behavior. This helps establish a therapeutic environment and maintains the safety and well-being of both the client and others in the milieu.
Allowing the client to refuse medications is an important aspect of respecting their autonomy and right to make decisions about their own care, as long as they are not posing a risk to themselves or others. It is important to communicate with the client about the potential consequences of refusing medications and provide information about the benefits of taking prescribed medications to support their mental health.
The other options are not appropriate for the following reasons:
A- Informing the client that a family member will be called to help: Involving family members can be helpful in some situations, but it should not be used as a way to manipulate the client into compliance with treatment. Calling a family member without the client's consent may also violate the client's privacy and autonomy.
B- Preparing discharge paperwork since the client is refusing assistance: Discharging the client solely because they are refusing medication may not be appropriate or ethical if they are not posing a threat to themselves or others. Discharging the client without addressing the underlying issues may not be in the client's best interest and may not resolve the disruptive behavior.
D- Informing the client that without medications, their mental status will not improve: While it is important to provide the client with information about the benefits of medication, using this information as a threat or coercion tactic may not be therapeutic or effective. The nurse should focus on building a trusting relationship with the client and supporting them in making informed decisions about their care.
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