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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Feelings are a key component of the psychological domain in the biopsychosocial model. This domain focuses on the client’s emotions, thoughts, and behaviors, which are crucial in understanding and treating mental health problems. Addressing feelings helps the nurse develop a comprehensive care plan that considers the client’s emotional well-being.
Choice B reason:
Cultural groups fall under the social domain of the biopsychosocial model. This domain includes factors such as family, community, and cultural influences on the client’s health. While cultural considerations are important, they are not part of the psychological domain.
Choice C reason:
Family functioning is also part of the social domain. It involves the dynamics and interactions within the client’s family that can impact their mental health. Understanding family functioning is essential, but it is not categorized under the psychological domain.
Choice D reason:
Sleep patterns can be influenced by both psychological and biological factors. However, in the context of the biopsychosocial model, sleep patterns are typically considered part of the biological domain. The psychological domain specifically addresses the client’s emotions and mental processes.
Correct Answer is B
Explanation
Choice A reason:
The 24-year-old only being the client would imply that the therapy session is focused solely on the individual issues of the 24-year-old. However, the context of the therapy session, which includes multiple family members, suggests that the focus is on addressing family dynamics and conflicts. Family therapy typically involves working with the entire family unit to improve relationships and resolve conflicts, rather than focusing on a single individual.
Choice B reason:
The entire family being the client is the correct answer because family therapy aims to address issues within the family system as a whole. By involving the 24-year-old, his sister, his mother, and the mother’s live-in boyfriend, the therapy session is designed to explore and resolve conflicts that affect the entire family. This approach recognizes that individual issues are often interconnected with family dynamics, and addressing these dynamics can lead to more effective and lasting solutions.
Choice C reason:
The 24-year-old and his mother being the clients would limit the scope of the therapy to the relationship between these two individuals. While this might address some aspects of the family conflict, it would not provide a comprehensive approach to resolving issues that involve other family members, such as the sister and the mother’s live-in boyfriend. Family therapy is most effective when all relevant members are included in the process.
Choice D reason:
The sister, mother, and 24-year-old being the clients would exclude the mother’s live-in boyfriend, who is also part of the family dynamic. Excluding any family member who is involved in the conflict can limit the effectiveness of the therapy. Family therapy aims to include all relevant members to fully understand and address the issues affecting the family as a whole. Therefore, this option is not as comprehensive as involving the entire family.
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