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:
Cognitive therapy focuses on changing negative thought patterns and behaviors through structured sessions with a therapist. While it is an effective treatment for many mental health conditions, it does not involve the structured daily routines described in the scenario. Cognitive therapy is typically conducted in individual or group sessions rather than through the daily activities of an inpatient unit.

Choice B reason:
Milieu therapy involves creating a therapeutic environment that supports the client’s recovery through structured daily routines and interactions with staff and peers. The emphasis on getting up at a certain time, attending meals, and taking medications on schedule is characteristic of milieu therapy. This approach helps clients develop healthy habits, social skills, and a sense of responsibility.

Choice C reason:
Family therapy involves working with the client and their family members to improve communication, resolve conflicts, and support the client’s recovery. While family therapy is an important component of comprehensive mental health care, it does not involve the structured daily routines described in the scenario. Family therapy sessions are typically scheduled separately from the client’s daily activities.

Choice D reason:
Electroconvulsive therapy (ECT) is a medical treatment that involves inducing controlled seizures to alleviate severe psychiatric symptoms. ECT is typically administered in a hospital setting under anesthesia and is not related to the structured daily routines described in the scenario. It is used for specific conditions, such as severe depression or treatment-resistant schizophrenia, and is not a form of therapy that involves daily activities.

A. Recent marriage B. Age greater than 55 C. Bachelor’s degree D. Male gender E. Diagnosis of schizophrenia

Correct Answer is ["B","D","E"]

Explanation

Choice A reason:
Recent marriage is generally considered a protective factor against suicide rather than a risk factor. Marriage can provide emotional support and stability, which can reduce the risk of suicidal behavior. However, the quality of the relationship and other individual factors should also be considered.
Choice B reason:
Age greater than 55 is a recognized risk factor for suicide, particularly among men. Older adults may face multiple stressors such as chronic illness, loss of loved ones, and social isolation, which can increase the risk of suicide. It is important to monitor and support older adults who may be at risk.
Choice C reason:
Having a bachelor’s degree is not typically associated with an increased risk of suicide. In fact, higher educational attainment is often linked to better mental health outcomes and access to resources. However, individual circumstances and stressors should always be considered.
Choice D reason:
Male gender is a significant risk factor for suicide. Men are more likely to die by suicide compared to women, although women may attempt suicide more frequently. This gender disparity is attributed to various factors, including the methods used and societal expectations around expressing emotions.
Choice E reason:
A diagnosis of schizophrenia is a known risk factor for suicide. Individuals with schizophrenia may experience severe symptoms, including delusions and hallucinations, which can contribute to suicidal thoughts and behaviors. It is crucial to provide comprehensive care and support to individuals with this diagnosis to mitigate the risk of suicide.

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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

Jaden is admitted to an inpatient psychiatric unit. During her time on the unit, Jaden is expected to get up at a certain time, attend breakfast at a certain time, and arrive for her medications at the correct time. What form of therapy is incorporated into this unit?

Correct Answer is B

Explanation

A nurse manager is discussing suicide with nursing staff. Which of the following should the manager identify as risk factors for suicide? (Select all that apply)

Correct Answer is ["B","D","E"]

Explanation

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?

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 a mental illness. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?

When engaged in therapeutic communication with a client who has been diagnosed with a mental disorder, which is the most important principle for a nurse to keep in mind?

While working with an older client, a nurse begins to think of the client as a grandparent and responds to the client as a grandchild. The nurse is developing what type of emotional reaction?

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?

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?