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?

“If your behavior continues, we have no choice but to place you in seclusion."

"You have to take this medication to settle you down and stop your behavior."

“I don't know what set you off today but you have to get along with others."

“Let’s go to a quiet area and talk about what is upsetting you."

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is D

Explanation

A-Positioning in semi-Fowler’s can aid breathing but doesn’t assess crackles’ cause. It’s supportive, not diagnostic, and premature without further data

B-Instructing the client to limit fluid intake to less than 2,000 mL/day is not indicated for crackles. Fluid restriction is more commonly used in conditions like congestive heart failure where there is excessive fluid retention.

C- Preparing to administer antibiotics is not the first intervention for crackles. Crackles can be caused by various conditions, and antibiotics would only be administered if there is an underlying infection requiring treatment.

D- Reassessing after deep breathing and coughing evaluates secretion clearance, aligning with nursing assessment and Maslow’s physiological needs

A. The nurse should examine their personal attitudes related to loss and grieving. B. The nurse will evaluate previous methods of interventions that were beneficial. C. The nurse will establish the goals for the process and present to the client. D. The nurse will share personal information for the client related to the loss experienced by the nurse

Correct Answer is A

Explanation

Prior to meeting with a client who is experiencing complicated grieving, the nurse should engage in self-reflection and examine their own attitudes, biases, and emotional responses related to loss and grieving. This is important because the nurse's own experiences and beliefs can influence their ability to provide empathetic and non-judgmental care to the client. By acknowledging and understanding their own feelings and reactions, the nurse can better support the client in their grieving process.

The other options are not appropriate for the following reasons:

B- Evaluating previous methods of interventions: While it is essential for the nurse to have knowledge and skills related to grief counseling and interventions, focusing solely on previous methods may not be helpful for the client's unique situation. Each individual's grieving process is different, and what worked for one client may not work for another.

C- Establishing goals for the process and presenting them to the client: While setting goals for the therapeutic relationship is important, it should be a collaborative process between the nurse and the client. The nurse should work with the client to identify their needs and goals related to the grieving process and develop a plan of care together.

D- Sharing personal information related to loss experienced by the nurse: It is not appropriate for the nurse to share their own personal experiences of loss with the client. The focus of the therapeutic relationship should be on the client's needs and experiences, not the nurse's. Sharing personal information can shift the focus away from the client and may not be helpful or therapeutic for them.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse auscultates a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take

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?

Correct Answer is A

Explanation

After an Angry outburst, a client quickly appears calmer and receptive to input from the nurse. Which is the most helpful response to the client at this time?

A client is observed pacing the hall with clenched fists and swearing at others. The nurse intervenes immediately in a calm manner to prevent the client from moving to which phase of the aggression cycle?

The nurse is working with a client at the battered women's shelter who is in a violent and abusive relationship. The client is considering a separation and asks the nurse. "What do you think about that?" Which is the best response by the nurse?

A nurse is assessing several clients who have experienced loss. Which client will the nurse identify as experiencing complicated grieving? Select all that apply. (Select All that Apply.)

The client with terminal lung cancer says to the nurse. "I really want to see my first grandchild born before I die. Is that too much to ask?" Which stage of grieving will the nurse document the client is experiencing?

A nurse is questioning another nurse about whether it is ethical to seclude a client because of loud and intrusive behavior on the unit. Which is the ethical principle that will best guide the nurse's decision on the appropriate use of seclusion?

An angry client has just thrown a chair across the room and is racing to pick up another chair to throw. Which is the most appropriate action by the nurse?

A client is manipulative with staff and disruptive in the milieu. Although the client is not demonstrating behaviors that are a threat to self or others, they are refusing all medications. Which action by the nurse is most appropriate?