The nurse is caring for several clients on the behavioral health unit. Which client will be assessed as demonstrating aggression?

A client who bursts into tears, leaves the group meeting, and sits on the bed hugging a pillow and sobbing

A client who stomps away from the nurses' station, goes into the day room, and grabs a pool cue from another client standing at the pool table

A client who tells the primary nurse "When you told me that I could not have a pass. I felt angry."

A client who tells the medication nurse, "I am not going to take that, or any other, medication."

The correct answer is B. A client who stomps away from the nurses' station, goes into the day room, and grabs a pool cue from another client standing at the pool table.

Answer and Explanation

The Correct Answer is B

Aggression is a behavior characterized by hostility, anger, or violent actions toward others or objects. In the scenario described in option B, the client demonstrates aggressive behavior by stomping away from the nurses' station and grabbing a pool cue from another client. This behavior indicates hostility and potential violence towards others, which is a clear example of aggression.

Options A, C, and D do not describe aggressive behavior. Option A describes a client expressing sadness and seeking comfort by hugging a pillow and sobbing. Option C describes a client expressing anger verbally but not exhibiting aggression. Option D describes a client refusing to take medication, which may not necessarily involve aggressive behavior.

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Correct Answer is D

Explanation

Explanation: This response demonstrates the use of therapeutic communication, specifically offering the client an opportunity to express their feelings and concerns in a non-confrontational manner. By suggesting a private and quiet area to talk to, the nurse provides a safe and supportive environment for the client to explore and process their emotions. This approach can help the client feel heard, validated, and understood, which may reduce their need to act out or engage in argumentative behaviors to express their feelings.

The other responses are not as effective or therapeutic:

A. Threatening the client with seclusion is an aggressive approach and may escalate the client's behavior or cause them to feel cornered and defensive, leading to further acting out.

B. Telling the client they have to take medication to stop their behavior does not address the underlying issues that may be causing their behavior. It can also come across as dismissive of the client's feelings and concerns.

C. Saying "I don't know what set you off today but you have to get along with others" may be perceived as dismissive and does not offer the client an opportunity to express their emotions or address their concerns.

In summary, offering a private space to talk and explore the client's feelings in a non-judgmental and supportive manner is the most beneficial therapeutic response to help the adolescent client decrease acting out behaviors and promote positive communication and coping skills.

A. The nurse must discuss the findings with the parents and give them the opportunity to explain. B. Talk to the child and find out if they are experiencing sexual abuse or inappropriate touching. C. The nurse should talk with another co-worker to be sure the nurse is correct about the assessment. D. Accurately and thoroughly document the findings and report to the appropriate authorities.

Correct Answer is D

Explanation

When a school nurse suspects that a child is being sexually abused, the priority action is to ensure the child's safety and well-being. Option D, accurately and thoroughly documenting the findings and reporting to the appropriate authorities, is the most critical step in protecting the child.

Child abuse, including sexual abuse, is a serious concern that requires immediate attention and intervention. In many jurisdictions, healthcare professionals, including school nurses, are mandated reporters, which means they are legally obligated to report suspected cases of child abuse to child protective services or other appropriate authorities.

Options A, B, and C are not appropriate as the child's safety is the top priority:

A. Discussing the findings with the parents and giving them the opportunity to explain could potentially place the child at further risk if the parents are involved in the abuse or are unwilling to address the situation.

B. Talking to the child and finding out if they are experiencing sexual abuse or inappropriate touching should not be the first step without involving child protective services or other appropriate authorities. The child may be frightened or reluctant to disclose abuse directly to the nurse, especially if the abuser is a family member or someone known to the child.

C. Talking with another co-worker to confirm the assessment may delay the necessary action and reporting to protect the child.

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The nurse is caring for several clients on the behavioral health unit. Which client will be assessed as demonstrating aggression?

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The nurse is working with an adolescent client that is argumentative with staff and peers on the behavioral health unit. Which therapeutic response will be most beneficial for the client to decrease acting out behavior?

Correct Answer is D

Explanation

The school nurse is seeing a 7-year-old child in the clinic and is concerned with behaviors and physical indications that indicate the child is being sexually abused. Which is the priority action by the nurse?

Correct Answer is D

Explanation

The nurse is meeting with a client who is experiencing complicated grieving from the death of their child to suicide. In order to establish a therapeutic nurse-client relationship, what will the nurse do prior to the meeting?

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