Which of the following interventions would a nurse use when caring for an inpatient client who expresses anger inappropriately?

Teach the client to avoid “I” statements related to the expression of feelings.

Tell the client to stop using a loud angry voice.

Use therapeutic touch to convey empathy.

Clearly explain the consequences of the behavior.

Answer and Explanation

The Correct Answer is D

Choice A Reason: Teach the client to avoid “I” statements related to the expression of feelings

Teaching a client to avoid “I” statements is not a recommended intervention. In fact, “I” statements are often encouraged in therapeutic settings because they help individuals express their feelings without blaming others. For example, saying “I feel angry when…” helps to communicate emotions constructively and can be a part of anger management strategies.

Choice B Reason: Tell the client to stop using a loud angry voice

While it might seem logical to ask a client to stop using a loud, angry voice, this approach can be counterproductive. It may escalate the situation by making the client feel unheard or invalidated. Instead, it is more effective to acknowledge the client’s feelings and then guide them towards expressing their anger in a more appropriate manner.

Choice C Reason: Use therapeutic touch to convey empathy

Therapeutic touch involves using physical touch to convey empathy and support. However, its effectiveness can vary depending on the client’s comfort with touch and cultural background. Some clients may find touch comforting, while others may find it intrusive or uncomfortable. Therefore, it is important to assess the client’s preferences and obtain consent before using therapeutic touch.

Choice D Reason: Clearly explain the consequences of the behavior

This is the correct answer. Clearly explaining the consequences of inappropriate behavior helps set boundaries and provides the client with an understanding of the impact of their actions. It is a crucial part of behavior management and helps the client learn appropriate ways to express their emotions. This approach is aligned with cognitive-behavioral strategies that focus on understanding the relationship between thoughts, feelings, and behaviors.

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Correct Answer is C

Explanation

Choice A Reason:

This response is inappropriate as it blurs the professional boundaries between the nurse and the client. Nurses are expected to maintain a professional relationship with their clients to ensure that care is provided in an ethical and unbiased manner. Suggesting a potential future relationship can lead to misunderstandings and compromise the therapeutic relationship.

Choice B Reason:

While this response correctly states hospital policy, it does not address the underlying issue of maintaining professional boundaries. It is important for the nurse to communicate the need for a professional relationship clearly and directly. Simply citing policy may not fully convey the importance of these boundaries to the client.

Choice C Reason:

This response is the most appropriate because it clearly establishes the professional nature of the nurse-client relationship. It helps the client understand that the nurse’s role is to provide care and support within a professional framework. This clarity is essential for maintaining trust and ensuring that the therapeutic relationship remains effective and ethical.

Choice D Reason:

Although this response sets a personal boundary, it does not address the professional aspect of the nurse-client relationship. The nurse’s marital status is irrelevant to the professional boundaries that need to be maintained. It is more important to emphasize the professional nature of the relationship rather than personal reasons for declining the request.

A. Administer the medication with food. B. Administer the medication to the client at night to avoid daytime sedation. C. Encourage the client to avoid drinking alcohol when taking this medication. D. Assess for history of smoking.

Correct Answer is C

Explanation

Choice A Reason:

Administer the medication with food.

Administering clonazepam with food can help reduce gastrointestinal discomfort, but it is not the most critical consideration. While it is beneficial to minimize potential side effects like nausea, it does not address the primary safety concerns associated with clonazepam use.

Choice B Reason:

Administer the medication to the client at night to avoid daytime sedation.

Administering clonazepam at night can help avoid daytime sedation, which is a common side effect of benzodiazepines. However, this is not the most critical safety concern. While managing sedation is important, it does not address the potential for more serious interactions and risks.

Choice C Reason:

Encourage the client to avoid drinking alcohol when taking this medication.

This is the correct response. Alcohol can significantly increase the sedative effects of clonazepam, leading to dangerous levels of sedation, respiratory depression, and even death. It is crucial to educate clients about the risks of combining alcohol with benzodiazepines to prevent potentially life-threatening interactions.

Choice D Reason:

Assess for history of smoking.

While assessing for a history of smoking is part of a comprehensive health assessment, it is not the most critical consideration when administering clonazepam. Smoking does not have the same immediate and severe interaction risks with clonazepam as alcohol does.

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Which of the following interventions would a nurse use when caring for an inpatient client who expresses anger inappropriately?

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