The nurse is performing an admission assessment for a client admitted to the behavioral health unit. Which social/cultural category will the nurse document that may be contributing to the client's degree of mental illness? Select all that apply. (Select All that Apply.)

When encountering a client who is sexually aggressive, it is important for the nurse to establish firm limits and boundaries to ensure the safety and well-being of both the client and the healthcare team. This response promotes the maintenance of a therapeutic environment and helps prevent potential harm to the client, staff, and other patients.

the other choices are incorrect:

1. "Tell the client that you are going to report to the director of the unit." While it is important to report any concerning behaviors or incidents to the appropriate personnel, simply informing the client about reporting to the director may not be the most effective initial response. Prioritizing immediate actions to ensure safety and setting boundaries is crucial before involving higher-level staff.

2. "Walk away and have someone else take care of the client." Leaving the situation and passing the responsibility to someone else without addressing the issue directly is not an appropriate response. It is the nurse's responsibility to provide care and manage challenging situations within their scope of practice and training. Collaboration and support from the healthcare team may be sought, but abandoning the client is not an acceptable approach.

3. "It happens frequently, so just ignore it; they will stop." Ignoring sexually aggressive behavior is not an appropriate response. Such behavior should be taken seriously and addressed promptly to ensure the safety and well-being of everyone involved. Ignoring the behavior may enable its continuation and potentially lead to further harm or escalation of the situation.

Systematic desensitization is a therapeutic technique used to help individuals gradually overcome their fears or phobias by exposing them to the feared stimulus in a controlled and systematic way. The goal is to reduce anxiety and increase relaxation through a step-by-step process.

The statement "What is the worst that will happen if you confront this fear?" aligns with the principle of systematic desensitization because it encourages the client to explore and challenge their negative beliefs or catastrophic thinking associated with their fear. By questioning the potential negative outcomes, the nurse is helping the client to reevaluate their fear response

and consider more realistic expectations. This process can contribute to the client's ability to confront their fear gradually and reduce anxiety over time.

The other statements are still helpful and supportive, but they do not specifically address the principles of systematic desensitization:

“I can see you are anxious. Let's stop for a minute." acknowledges the client's anxiety but does not actively engage in the technique of systematic desensitization.

"Use the deep breathing techniques we practiced yesterday." focuses on relaxation techniques, which can be helpful in managing anxiety but does not specifically address the principles of systematic desensitization.

“Tell me how you are feeling right now." encourages the client to express their feelings but does not directly engage in the technique of systematic desensitization.