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.

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Correct Answer is B

Explanation

Choice A reason:
A predictable social environment is important for providing stability and security, which can contribute to a client’s overall well-being. However, according to Maslow’s hierarchy of needs, physiological needs such as food and water must be met before higher-level needs like social stability can be addressed. Therefore, while important, a predictable social environment is not the immediate priority.
Choice B reason:
Adequate food is a fundamental physiological need according to Maslow’s hierarchy of needs. Physiological needs are the most basic and must be satisfied before an individual can focus on higher-level needs such as safety, love, and self-esteem. Ensuring that the client has adequate food is essential for their survival and overall health, making it the top priority in the plan of care.
Choice C reason:
A positive self-image is associated with self-esteem needs, which are higher up in Maslow’s hierarchy. While fostering a positive self-image is important for a client’s mental health and well-being, it cannot be effectively addressed until basic physiological needs are met. Therefore, it is not the immediate priority in the plan of care.
Choice D reason:
Acceptance from family relates to the need for love and belonging, which is also higher up in Maslow’s hierarchy. While family acceptance is crucial for emotional support and social well-being, it is not as immediate a priority as ensuring that the client’s basic physiological needs, such as adequate food, are met first.

A. “I think that the federal government is spying on me.” B. “That doctor I had today really made me angry.” C. “I get really ‘turned on’ by your appearance.” D. “When I get out of here, I’m going to make my neighbor sorry.”

Correct Answer is D

Explanation

Choice A reason:
The statement “I think that the federal government is spying on me” reflects a delusional belief, which is a symptom of certain mental health disorders. While this statement indicates the need for further assessment and possibly treatment, it does not pose an immediate threat to the safety of the client or others. Therefore, it does not warrant breaching confidentiality.

Choice B reason:
Expressing anger towards a doctor, as in the statement “That doctor I had today really made me angry,” is not uncommon in a mental health setting. While it may indicate dissatisfaction or a need for conflict resolution, it does not suggest an immediate risk of harm to the client or others. Confidentiality should be maintained unless there is a clear and imminent threat.

Choice C reason:
The statement “I get really ‘turned on’ by your appearance” is inappropriate and may indicate boundary issues or sexual attraction towards the nurse. While this requires professional handling and possibly setting boundaries, it does not constitute a threat that would necessitate breaching confidentiality.

Choice D reason:
The statement “When I get out of here, I’m going to make my neighbor sorry” indicates a specific threat of harm towards another person. Nurses are legally and ethically obligated to breach confidentiality in situations where there is a clear and imminent risk of harm to the client or others. This duty to warn and protect overrides the obligation to maintain confidentiality.

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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

A nurse is developing a plan of care integrating Maslow’s hierarchy of needs. Which area would the nurse identify as the priority?

Correct Answer is B

Explanation

A nurse is caring for a client who is hospitalized for a mental disorder. The nurse is legally obligated to breach the client’s confidentiality if the client makes which statement?

Correct Answer is D

Explanation

After being scolded by his supervisor at work, a man comes home and punches several holes in his walls and yells at his significant other. Which of the following defense mechanisms does this scenario depict?

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?

A nurse is providing education to a group of staff members about schizophrenia. Which of the following age groups should the nurse include as the age when schizophrenia is typically diagnosed?

When communicating with a client, which would a nurse use to convey positive body language?

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?

After experiencing increasing conflict in the home, a social worker calls and schedules a therapy meeting. A 24-year-old, his sister, his mother, and the mother’s live-in boyfriend are asked to attend the therapy meeting. Who is the “client” who will be treated during this session?