Page 2294 - Saunders Comprehensive Review For NCLEX-RN

question. Remember that if a physiological need is not present, focus on safety. Look
for the option that promotes safety of the client, other clients, and staff.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process—Implementation
Content Area: Mental Health
Health Problem: Mental Health: Violence
Priority Concepts: Mood and Affect; Safety
Reference: Varcarolis (2017), pp. 378-379.

811. Answer: 1, 3, 4, 6

Rationale: Interventions for dealing with the client exhibiting manipulative
behavior include setting clear, consistent, and enforceable limits on manipulative
behaviors; being clear with the client regarding the consequences of exceeding the
limits set; following through with the consequences in a nonpunitive manner; and
assisting the client in identifying a means of setting limits on personal behaviors.
Ensuring that the client knows that she or he is not in charge of the nursing unit is
inappropriate; power struggles need to be avoided. Enforcing rules and informing
the client that she or he will not be allowed to attend therapy groups is a violation of
a client’s rights.
Test-Taking Strategy: Focus on the subject, manipulative behavior. Recalling
clients’ rights and that power struggles need to be avoided will assist in selecting the
correct interventions.
Level of Cognitive Ability: Analyzing
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Mental Health
Health Problem: Mental Health: Mood Disorders
Priority Concepts: Clinical Judgment; Mood and Affect
Reference: Varcarolis (2017), p. 233.

812. Answer: 1

Rationale: Safety of the client and other clients is the immediate priority. The
correct option is the only one that addresses the safety needs of the client as well as
those of the other clients.
Test-Taking Strategy: Note the strategic words, immediate priority, and use
Maslow’s Hierarchy of Needs theory to prioritize. Note the words agitated,
aggressive, and belligerent. Safety is the priority focus if a physiological need does not
exist. Also, the correct option is the umbrella option and addresses the safety of all.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process—Implementation
Content Area: Mental Health
Health Problem: Mental Health: Violence
Priority Concepts: Mood and Affect; Safety

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