During group therapy, the nurse observes that a client is pacing, agitated, and presenting with aggressive gestures. The client’s speech pattern is rapid, and affect is belligerent. Based on the observations, the nurse’s immediate priority of care is to:

Assist the staff in caring for the client in a controlled environment

Provide safety for the client and other clients on the unit

Provide the clients on the unit with a sense of comfort and safety

Offer the client a less stimulated area to calm down and gain control

Answer and Explanation

The Correct Answer is B

Choice A reason:
While assisting the staff in caring for the client in a controlled environment is important, the immediate priority is to ensure safety. This choice does not directly address the immediate need to protect all clients from potential harm.

Choice B reason:
Providing safety for the client and other clients on the unit is the immediate priority. The client’s aggressive behavior poses a risk to themselves and others, and ensuring safety is the first step in managing the situation. This involves de-escalation techniques and possibly removing the client from the group setting to prevent harm.

Choice C reason:
Providing a sense of comfort and safety is important but secondary to ensuring immediate physical safety. The client’s aggressive behavior needs to be managed first to prevent any potential harm.

Choice D reason:
Offering the client a less stimulated area to calm down is a good strategy for de-escalation, but it comes after ensuring the immediate safety of all clients. The primary concern is to prevent any aggressive actions that could harm others.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason:

A teenager who refuses to participate in the planned therapy does not necessarily meet the criteria for involuntary commitment. Refusal to participate in therapy can be addressed through other means, such as motivational interviewing or adjusting the treatment plan to better engage the client.

Choice B reason:

A 24-year-old client who refuses to take the prescribed medication also does not automatically qualify for involuntary commitment. Non-compliance with medication can be managed through education, support, and exploring the reasons behind the refusal. Involuntary commitment is typically reserved for situations where the client poses a danger to themselves or others.

Choice C reason:

A 45-year-old client who is homeless and has been diagnosed with a mental disorder may need support and resources, but homelessness and a mental health diagnosis alone do not justify involuntary commitment. The focus should be on providing housing and mental health services rather than involuntary hospitalization.

Choice D reason:

An elderly client who is confused, screaming obscenities in the street, and disturbing neighbors is exhibiting behavior that may pose a risk to themselves or others. This situation suggests a level of acute distress or potential danger that could warrant involuntary commitment to ensure the client’s safety and provide necessary treatment.

A. Developmental B. Humanistic C. Cognitive D. Behavioral

Correct Answer is D

Explanation

Choice A reason:
Developmental theories focus on the progression of human growth and development through various stages of life. While these theories are important in understanding patient behavior and needs, they do not directly relate to the implementation of a privilege system in an inpatient unit. Privilege systems are more aligned with behavioral theories, which emphasize the modification of behavior through reinforcement and consequences.

Choice B reason:
Humanistic theories emphasize the individual’s capacity for self-actualization and personal growth. These theories focus on the holistic development of the person and the importance of empathy and unconditional positive regard in therapeutic relationships. Although humanistic approaches are valuable in mental health care, they do not specifically address the structured reinforcement strategies used in privilege systems.

Choice C reason:
Cognitive theories focus on the role of thought processes in influencing emotions and behaviors. These theories are crucial in understanding and treating mental health conditions, particularly through cognitive-behavioral therapy (CBT). However, the privilege system, which relies on tangible rewards and consequences to shape behavior, is more closely related to behavioral theories rather than cognitive ones.

Choice D reason:
Behavioral theories are directly related to the use of a privilege system. These theories emphasize the use of reinforcement and punishment to modify behavior. In an inpatient setting, a privilege system is used to encourage desirable behaviors by providing rewards (privileges) and discouraging undesirable behaviors through the removal of privileges. This approach is grounded in the principles of operant conditioning, a key concept in behavioral theories.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

During group therapy, the nurse observes that a client is pacing, agitated, and presenting with aggressive gestures. The client’s speech pattern is rapid, and affect is belligerent. Based on the observations, the nurse’s immediate priority of care is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client would a nurse determine to be the most likely candidate for involuntary commitment?

Correct Answer is D

Explanation

A psychiatric-mental health nurse is working on an inpatient unit that uses a privilege system. The nurse understands that this intervention integrates which group of theories?

Correct Answer is D

Explanation

When providing care to a client diagnosed with a mental disorder, the client asks the nurse, “Does mental illness run in your family?” Which response by the nurse would be nontherapeutic?

A nurse is caring for a client who has schizophrenia and is taking haloperidol. The nurse should monitor for which of the following adverse effects of haloperidol?

A nurse is caring for a client who has a mental illness. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?

A woman comes into the Emergency Department in a severe state of anxiety following a car accident. The appropriate nursing intervention is to:

The charge nurse is talking with another nurse who states, “I feel like my clients have no interest in their care and do not care that I am trying to help.” Which response should the charge nurse make?

During group therapy, the nurse observes that a client is pacing, agitated, and presenting with aggressive gestures. The client’s speech pattern is rapid, and affect is belligerent. Based on the observations, the nurse’s immediate priority of care is to:

A nurse is preparing to assist with electroconvulsive therapy (ECT). Which of the following pieces of equipment should the nurse set up in the room prior to the treatment? (Select all that apply)