Difficulty: Medium
Average Score: 76%
Simulated
A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should the nurse take?
Correct answer
C
Rationale
Correct Answer: C
Rationale: Talking to the client and identifying specific behavior limits is the most appropriate initial action. This approach allows the nurse to address the issue directly with the client, set clear expectations, and provide an opportunity for the client to understand the impact of their behavior on others. It promotes open communication and establishes boundaries.
Incorrect Choices:
A: Discussing the problem in a community meeting may embarrass the client and could lead to further conflict.
B: Constantly escorting the client to her room does not address the underlying issue and may not be feasible in the long term.
D: Telling other clients to ignore the lies does not address the root cause of the problem and may not be effective in resolving the issue.
Rationale: Talking to the client and identifying specific behavior limits is the most appropriate initial action. This approach allows the nurse to address the issue directly with the client, set clear expectations, and provide an opportunity for the client to understand the impact of their behavior on others. It promotes open communication and establishes boundaries.
Incorrect Choices:
A: Discussing the problem in a community meeting may embarrass the client and could lead to further conflict.
B: Constantly escorting the client to her room does not address the underlying issue and may not be feasible in the long term.
D: Telling other clients to ignore the lies does not address the root cause of the problem and may not be effective in resolving the issue.