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:
While this response acknowledges the nurse’s feelings, it does not provide a constructive solution or address the underlying issue. It may come across as dismissive rather than supportive.

Choice B reason:
Establishing a therapeutic relationship is fundamental to effective nursing care. This response encourages the nurse to build rapport and trust with the clients, which can improve their engagement and cooperation in their care. It is a proactive and supportive suggestion.

Choice C reason:
Offering to assign another nurse does not address the issue of building a therapeutic relationship and may not be feasible. It also does not help the nurse develop skills to improve client interactions.

Choice D reason:
While clients in pain may exhibit disinterest, this response does not address the broader issue of establishing a therapeutic relationship. It focuses on a specific cause rather than providing a general strategy for improving client engagement.

A. EXPLAINING UNIT RULES AND POLICIES REGARDING UNACCEPTABLE BEHAVIORS B. SUPPORTING THE CLIENT’S WISH TO REFUSE PRESCRIBED MEDICATIONS C. MAKING SURE THE CLIENT UNDERSTANDS EXPECTATIONS FOR CLIENT PARTICIPATION D. ENCOURAGING CLIENT FEEDBACK ABOUT SATISFACTION WITH THE FACILITY EXPERIENCE

Correct Answer is B

Explanation

Choice A reason:
Explaining unit rules and policies regarding unacceptable behaviors is important for maintaining order and safety within the facility. However, this action is more about setting boundaries and expectations rather than supporting the client’s autonomy. Autonomy involves respecting the client’s right to make their own decisions, which is not directly addressed by merely explaining rules.
Choice B reason:
Supporting the client’s wish to refuse prescribed medications demonstrates respect for the client’s autonomy. Autonomy is the ethical principle that recognizes the right of individuals to make informed decisions about their own care. By supporting the client’s decision to refuse medication, the nurse acknowledges and respects the client’s right to make choices about their treatment, even if those choices differ from medical advice.
Choice C reason:
Making sure the client understands expectations for client participation is essential for clear communication and effective treatment planning. However, this action is more about ensuring compliance and understanding rather than promoting autonomy. While it is important for clients to understand what is expected of them, this does not necessarily empower them to make their own decisions.
Choice D reason:
Encouraging client feedback about satisfaction with the facility experience is a valuable practice for improving care and ensuring that clients feel heard. However, this action focuses on gathering feedback rather than directly supporting the client’s autonomy. While it contributes to a client-centered approach, it does not specifically address the client’s right to make independent decisions about their care.

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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:

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

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?

Correct Answer is B

Explanation

A client receives a court order for commitment. Which concept exemplifies a “least restrictive environment”?

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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?

A nurse is developing a plan of care for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?

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)

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:

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

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?