The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Alert the assigned staff to closely monitor client and intervene as needed to reduce risk of selfmutilation.

Provide the client time alone in the client's room to reduce external stimulation and promote relaxation.

Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed.

Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm.

Answer and Explanation

The Correct Answer is A

A. The client's increased body tension and pacing indicate escalating distress and potential risk for self-harm. Alerting staff to closely monitor the client and intervene as needed is crucial to ensure the client's safety.
B. Providing time alone in the client's room may be appropriate in some situations but may not address the immediate risk of self-mutilation if the client is experiencing escalating distress. C. Giving firm, consistent expectations about self-mutilating behaviors is important for establishing boundaries, but it may not be sufficient to address the immediate risk of self-harm without additional monitoring and intervention.
D. Completing a thorough room search is important for safety but may not address the immediate risk of self-harm if the client is already exhibiting signs of distress and pacing in the hallway.

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Correct Answer is D

Explanation

Rationale for A: The phrase "Client claims" may imply doubt or a lack of belief in the client's account. It's important to use non-judgmental language that reflects the client's words without interpretation or bias. This choice is less appropriate because it doesn't use the client's exact words.

Rationale for B: This statement generalizes the situation and lacks the specificity of the client’s actual words. It may not capture the emotional impact or the client's clear identification of the event as rape. Direct quotations are preferred for documenting sensitive situations like this.

Rationale for C: While "Client has been sexually assaulted" is accurate, it is a general term. It is preferable to document the client's own words verbatim in the medical record to ensure clarity and to avoid any misinterpretation or assumptions.

Rationale for D: Documenting the client's exact words ("My date raped me tonight") ensures that the medical record accurately reflects the client's experience without interpretation. It is crucial to use the client's own language when documenting incidents of sexual assault.

A. Reinforce the need for the adolescent to attend group therapy sessions. B. Tell the mother to describe her feelings of helplessness to her child. C. Advise the mother to call the police if violent behavior occurs again. D. Refer the mother for psychiatric evaluation for anxiety and depression.

Correct Answer is C

Explanation

A. While reinforcing the need for group therapy sessions is important, it does not address the immediate safety concerns associated with violent behavior. Therapy is a long-term solution, but immediate action is necessary to prevent harm.
B. Telling the mother to describe her feelings of helplessness to the adolescent is not appropriate. It may increase the adolescent's frustration or aggression, rather than de-escalating the situation.
C. Advising the mother to call the police if violent behavior occurs again is the most important intervention. Violent actions, such as putting a fist through a window, indicate a risk for harm to self or others, and law enforcement intervention may be needed to ensure safety.
D. Referring the mother for psychiatric evaluation may be helpful if she is experiencing anxiety or depression, but it does not address the immediate concern of the adolescent's violent behavior.

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The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A young female client is admitted to the emergency room because she was raped that evening by her date. Which computer documentation should the nurse enter in the electronic medical record as the client's chief complaint?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

Which intervention(s) should the nurse include in the plan of care for an adolescent client who is depressed? Select all that apply.

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