Which should the mental health nurse identify as the priority for a newly admitted client who was involuntarily committed after reports by a co- worker of aggressive behavior?
Client and staff safety
Medication compliance
Client education
Group participation
The Correct Answer is A
a. Client and staff safety: This is correct because ensuring the safety of both the client and staff is the top priority, especially in cases of reported aggression.
b. Medication compliance: While medication compliance is important, it is secondary to ensuring immediate safety in this scenario.
c. Client education: Client education is valuable but may not be the immediate priority when safety concerns are present.
d. Group participation: While group participation may be beneficial for the client's treatment, it is not the priority when safety issues are at stake.
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Correct Answer is B
Explanation
a. Anticipate the behavior and restrain when pacing begins: Restraint should be a last resort. Pacing might not necessarily lead to screaming, and early intervention should focus on de-escalation techniques.
b. Assess environmental triggers and potential unmet needs. De-escalation strategies should prioritize understanding why the client's behavior is escalating. Identifying environmental triggers or unmet needs (like pain, hunger, thirst) can help prevent further agitation.
c. Assess for potential injury: While assessing for injury is important, it should come after ensuring the safety of both the client and the staff by addressing the cause of the outburst.
d. Consult the psychologist regarding behavior modification techniques: Consultation is valuable, but immediate intervention to de-escalate the situation and understand the cause is the priority.
Correct Answer is D
Explanation
a. "I know I can't use physical force anymore, but I can intimidate someone with my words." This indicates that the client still considers using intimidation, which is not a healthy way of managing anger or aggression.
b. "Because my wife seems to be the one to set me off, I've decided never to see her again." Avoiding a trigger rather than managing the response to it does not indicate progress in anger and aggression management.
c. "It's bad to feel as angry as I feel. I'm working on eliminating this evil feeling completely." Viewing anger as entirely negative and trying to eliminate it rather than managing it constructively does not show effective anger management.
d. "I realize I have a problem expressing my anger appropriately." This is correct because recognizing and admitting the problem is a critical first step toward making meaningful changes in managing anger and aggression.
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