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.
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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Naxlex Comprehensive Predictor Exams
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Correct Answer is A
Explanation
The potential issue that the nursing staff and hospital may have to defend against in this scenario is A. "malpractice."
Explanation: Malpractice refers to a legal claim that can be made against healthcare professionals, including nurses and hospitals, when they fail to provide the standard of care expected in their profession, resulting in harm or injury to a patient. In this case, the lack of documentation that the client was assessed every hour as prescribed can be seen as a failure to meet the standard of care for a client with depression, especially one at risk for self-harm or suicide. If the client attempted suicide in the bathroom and sustained an injury, it could be argued that the lack of proper assessment and monitoring contributed to the client's harm, and this failure to provide appropriate care might be considered malpractice.
The other options, "battery," "false imprisonment," and "assault," do not directly relate to the situation described in the scenario:
B- Battery refers to the intentional harmful or offensive contact with a person without their consent. There is no indication that this occurred in the scenario.
C- False imprisonment refers to the unlawful restraint or restriction of a person's freedom of movement without proper justification. There is no indication of false imprisonment in the scenario.
D- Assault refers to the intentional act of threatening or causing fear of harm to another person. While the client did sustain an injury, there is no indication that it was due to an intentional act of assault in this scenario.
In summary, the potential issue of malpractice arises from the failure to properly assess and monitor a client at risk for self-harm, resulting in harm to the client. The nursing staff and hospital may have to defend against this claim if it is determined that they did not meet the standard of care expected in such a situation.
Correct Answer is C
Explanation
The client's statement, "I really want to see my first grandchild born before I die. Is that too much to ask?" indicates that the client is experiencing the stage of bargaining in the grieving process. During this stage, individuals may try to negotiate or make deals with a higher power or with fate in an attempt to postpone or change the outcome of their situation. In this case, the client is expressing a desire to live long enough to witness the birth of their first grandchild, which represents an attempt to negotiate with their illness and impending death.
It's important for the nurse to be supportive and empathetic during this stage of grieving and to provide emotional support to the client as they navigate their feelings and thoughts about their illness and impending death. Explanation: The client's statement, "I really want to see my first grandchild born before I die. Is that too much to ask?" indicates that the client is experiencing the stage of grieving known as bargaining.
In the context of the five stages of grief proposed by Elisabeth Kübler-Ross, bargaining is the third stage. During this stage, individuals may attempt to negotiate or make deals with a higher power or the universe to change the outcome of their situation. They may express thoughts like "If only I could see this happen before I die," as a way to find some sense of control or hope amidst their terminal illness.
In this scenario, the client's desire to see their first grandchild born reflects the bargaining stage, where they are trying to find meaning and hope in their terminal condition by wishing for a specific event to occur before their passing.
The other stages of grief include:
A. Anger - In this stage, individuals may feel resentful, frustrated, or outraged about their situation or the circumstances leading to their illness.
B. Acceptance - The final stage in Kübler-Ross's model, acceptance, involves coming to terms with one's imminent death and finding peace and resolution.
D. Depression - In this stage, individuals may experience profound sadness and a sense of loss related to their impending death and the life they will leave behind.
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