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. “Mental illnesses do run in families, and I’ve had a lot of experience caring for people with mental illness.” B. “Mental illness can be family related. Let’s focus the discussion on you and how you’re doing today.” C. “It sounds like you are concerned that there may be a family connection to your current problem.” D. “Yes, it does. I have a sister who was diagnosed several years ago with severe major depression.”

Correct Answer is D

Explanation

Choice A reason:
This response provides general information about the hereditary nature of mental illnesses and reassures the client of the nurse’s experience. It maintains a professional boundary and does not disclose personal information, making it a therapeutic response.

Choice B reason:
This response acknowledges the client’s concern about the hereditary nature of mental illness and redirects the focus back to the client’s current situation. It is a therapeutic response that maintains professional boundaries and keeps the conversation client-centered.

Choice C reason:
This response validates the client’s concern and encourages further discussion about their feelings and experiences. It is a therapeutic response that promotes open communication and understanding.

Choice D reason:
Disclosing personal information about the nurse’s family can blur professional boundaries and shift the focus away from the client. It is considered nontherapeutic because it may make the client feel uncomfortable or distract from their own issues.

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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

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?

Correct Answer is D

Explanation

A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

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?

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 home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. The client is sitting on his front porch with a shotgun in his arms. Which of the following actions should the nurse take?

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?

The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions?

A nurse is discussing quality of life with a client who has schizophrenia. Which of the following statements should the nurse include?

A nurse is caring for a client who has bipolar disorder. The client says to the nurse, “Give me your pen to cut the pain out of my chest.” The nurse should identify that the client is at risk for which of the following?