Which nursing intervention is most beneficial for

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Question 1 of 5

Which nursing intervention is most beneficial for the client's spouse at this time?

A. Suggesting that the spouse make an appointment for a physical examination B. Discussing modifying the amount of time the spouse devotes to care-giving C. Reminding the spouse of the scheduled times for visiting clients on the unit D. Explaining that many staff are available to care for the client

Correct Answer: B

Rationale: Modifying caregiving time reduces exhaustion, supporting the spouse's well-being while maintaining care responsibilities.

Question 2 of 5

The client is admitted to the ED with multiple lacerations and broken bones after being assaulted. The client’s spouse barges into the client’s ED room with a gun and states “I’m going to kill you and anyone else who gets in my way.” Which action should be taken by the nurse initially?

A. Yell for help to distract the person’s attention away from the client. B. Firmly state “You don’t want to hurt anyone else. Let’s talk about it.” C. Use gestures to alert another nurse to clear others who may be nearby. D. Use a nonaggressive posture and tone to state “Put the gun on the floor.”

Correct Answer: D

Rationale: Using a nonaggressive posture and tone (
D) to request the gun be placed down de-escalates the situation safely. Yelling (
A) may startle and escalate assuming intent (
B) blocks communication and gesturing (
C) risks escalation if noticed.

Question 3 of 5

The new nurse is working with the cognitively impaired client who has a history of violent behavior. Which statement made by the new nurse reflects an immediate need for follow-up by the mentor?

A. “My first concern is the safety of all those on the unit.” B. “I know to turn off the television when the client starts pacing the floor.” C. “When the client started getting aggressive I tried talking the client down.” D. “I’m going to try and assign the same staff to work with the client each shift.”

Correct Answer: C

Rationale: Talking during aggression (
C) adds stimuli and requires mentor follow-up. Safety focus (
A) reducing stimuli (
B) and consistent staff (
D) are appropriate.

Question 4 of 5

The client who recently emigrated from Iran is on the mental health unit and has been placed in seclusion. The nurse assesses that the client is now calm and ready to be assimilated back into the mental health milieu. Which action by the nurse demonstrates cultural insensitivity?

A. Gives the client a thumbs-up gesture B. Avoids looking at the clock or a watch C. Has the NA bring the client a cup of tea D. Offers to bring the client the book of Quran

Correct Answer: A

Rationale: A thumbs-up (
A) is offensive in Iranian culture akin to a vulgar gesture. Avoiding clocks (
B) offering tea (
C) and providing the Quran (
D) are culturally appropriate.

Question 5 of 5

When debriefing the unit’s staff after the client’s catastrophic reaction the nurse stresses the need for the staff to remain calm during the event. Which statement should be the basis for the nurse’s comment?

A. The client’s safety is at jeopardy if the staff is feeling threatened. B. An agitated staff will not be able to manage the situation as effectively. C. The client will sense the staff’s agitation and aggressive behavior will escalate. D. An agitated staff response is indicative of a need for additional crisis-control training.

Correct Answer: C

Rationale: Staff agitation escalates client aggression (
C). Safety (
A) management (
B) and training (
D) are secondary concerns.

Nurselytic

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Mental Health NCLEX Questions

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