Documentation in a client's chart includes the following ...

[asmith134]

Documentation in a client's chart includes the following information: Throughout a 5-minute
  interaction the client fidgeted and tapped his left foot, periodically covered his face with his hands,
  looked under his chair, all while stating he
 
  was enjoying spending time with this nurse.. Of the
  following assessments, which is most accurate?
  a. The client is giving positive feedback about the nurse's communication
  techniques.
  b. The nurse is viewing the client's behavior through a cultural filter.
  c. The client's verbal and nonverbal messages are incongruent.
  d. The client is demonstrating psychotic behaviors.

Question 2

The nurse observes a client's anger escalating. He begins to pace the hall and shouts You all had
  better watch out.
 
  I'm going to hurt anybody who gets in my way.. Assuming each of the following
  interventions is appropriate, put them in the order in which they should occur. (Type answer in order
  from first to last.)
  A. Take the client to a seclusion room and administer medication.
  B. Have a nurse prepare prn medication.
  C. Calmly tell the client that staff will help you control your impulse to hurt someone..
  D. Gather a show of force.
  E. Remove clients from the area.

[skipfourms123]

Answer to Question 1

ANS: C
When a verbal message is not reinforced with nonverbal behavior, the message is confusing and
incongruent. Some clinicians call it a mixed message.. Option A is an inaccurate statement. Option
B: A cultural filter determines what we will pay attention to and what we will ignore. This concept is
not relevant to the situation presented. Option D: Data are insufficient to draw this conclusion.

Answer to Question 2

ANS: E, C, B, D, A
Rationale: The ideal sequence provides a rapid, organized response that provides safety for the other
clients and progresses from verbal limit setting to immobilization and concurrent use of medication.