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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Shortness of breath and diaphoresis are more indicative of a medical condition such as a panic attack or cardiovascular problem rather than a conversion disorder.
B. Sudden blindness with no organic pathology suggests a functional neurological symptom disorder, which falls under the category of conversion disorder.
C. Continuous complaints of headache and back pain could be symptoms of various medical conditions and may not specifically indicate a conversion disorder.
D. Extreme anxiety about going outside may indicate agoraphobia or another anxiety disorder rather than a conversion disorder.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
-The client talks to her father and her best friend when she starts to feel sad. Effective: Seeking support from loved ones and communicating feelings is a positive coping mechanism for dealing with sadness.
-The client states she feels numb when thinking about the crash.
Ineffective: Feeling numb can indicate emotional detachment, which may suggest unresolved trauma and could be indicative of ineffective treatment.
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-The client states that she avoids driving altogether and takes the bus.
Effective: Avoiding triggering situations, such as driving, can be a healthy coping strategy to manage distress associated with traumatic events.
-The client reports sleeping 6 to 7 hours per night.
Effective: Sleeping adequately is essential for mental health and overall well-being. Reporting sufficient sleep suggests improvement.
-The client states she feels less jumpy and more relaxed.
Effective: Feeling less jumpy and more relaxed indicates a reduction in anxiety symptoms, suggesting that treatment has been effective in managing anxiety.
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