The home health aide reports to the practical nurse that the client has been trying to give away possessions.

When the nurse asks the client about this behavior, the client says, “With my spouse dead, there’s no reason for me to go on.”. What is the best priority response by the nurse?

“Tell me more about how you’re feeling.”.

“You’re not thinking of killing yourself, are you?”

“Have you thought of therapy?”

“Let’s discuss some coping strategies.”.

Answer and Explanation

The Correct Answer is A

Choice A rationale
When a client expresses feelings of hopelessness and exhibits behaviors such as giving away possessions, it is crucial for the nurse to further explore these feelings. Asking the client to elaborate on their feelings allows the nurse to gather more information and assess the severity of the client’s emotional state. It also communicates to the client that the nurse is there to listen and provide support.
Choice B rationale
While it is important to assess for suicidal ideation in clients expressing hopelessness, asking directly, “You’re not thinking of killing yourself, are you?” can come across as confrontational and may cause the client to become defensive or close off.
Choice C rationale
Suggesting therapy is a potential intervention, but it is not the best initial response. The immediate priority is to assess the client’s emotional state and risk for self-harm.
Choice D rationale
Discussing coping strategies may be beneficial once the client’s immediate emotional state and safety have been addressed. However, it is not the best initial response when a client is expressing intense feelings of hopelessness.

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Correct Answer is D

Explanation

Choice A rationale
Walking away from the nurses’ station, heading to the hallway, and taking a tray from the meal cart is not necessarily aggressive behavior. It could be seen as a person simply going about their day or fulfilling a need such as hunger.
Choice B rationale
Expressing feelings of anger towards a primary nurse about not being able to have a second helping at lunch is not an aggressive behavior. It’s a form of assertive communication where the person is openly expressing their feelings and needs in a respectful manner.
Choice C rationale
Bursting into tears, leaving a community meeting, and sitting on a bed hugging a pillow and crying is more of an emotional response rather than an aggressive behavior. It could indicate sadness, frustration, or feeling overwhelmed, but it doesn’t involve any harm or intent to harm others.
Choice D rationale
Telling the medication nurse, “I am not going to take that, or any other, medication you try to give me” can be considered an aggressive behavior. This statement shows a refusal to cooperate and a confrontational attitude, which are characteristics of aggressive behavior.

A. The patient interpreted the UAP’s behavior as potentially harmful. B. Older adult patients often demonstrate exaggerations of behaviors used earlier in life. C. The patient learned violent behavior by watching other patients act out. D. Crowding in skilled nursing facilities increases an individual’s tendency toward violence.

Correct Answer is A

Explanation

Choice A rationale
The patient likely interpreted the UAP’s behavior as potentially harmful. This is a common reaction in confused older adults, especially when they are awakened unexpectedly. The patient may not have fully understood the situation and reacted out of fear or confusion.
Choice B rationale
While it’s true that older adults can sometimes demonstrate exaggerations of behaviors used earlier in life, there’s no information in the scenario to suggest this is the case.
Choice C rationale
There’s no evidence to suggest that the patient learned violent behavior by watching other patients act out. It’s more likely that the patient reacted out of fear or confusion.
Choice D rationale
While crowding can increase stress and agitation in some individuals, there’s no information in the scenario to suggest that this is a factor in the patient’s behavior.

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The home health aide reports to the practical nurse that the client has been trying to give away possessions. When the nurse asks the client about this behavior, the client says, “With my spouse dead, there’s no reason for me to go on.”. What is the best priority response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following actions is the best example of aggressive behavior?

Correct Answer is D

Explanation

A confused older adult patient in a skilled nursing facility was asleep when unlicensed assistive personnel (UAP) entered the room quietly and touched the bed to see if it was wet. The patient awakened and hit the UAP in the face. Which statement best explains the patient’s action?

Correct Answer is A

Explanation

True or False: Lability is characterized by a rapid change in emotions.

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The home health aide reports to the practical nurse that the client has been trying to give away possessions.

When the nurse asks the client about this behavior, the client says, “With my spouse dead, there’s no reason for me to go on.”. What is the best priority response by the nurse?