Practice Question
A client on the psychiatric unit is making sexual advances toward a nurse. Which action should this nurse implement first?
Answer Choices:
Correct Answer:
Tell the client in a matter-of-fact manner to stop the sexual advances.
Rationale:
🟪 Setting a clear, direct boundary is the priority to immediately stop inappropriate behavior.
🟪 A matter-of-fact response avoids shaming while reinforcing professional limits.
🟪 Establishing boundaries helps maintain a safe therapeutic environment for both the client and the nurse.
🟪 Clear direction reduces escalation and prevents further boundary violations.
🟪 This is consistent with psychiatric nursing principles of limit setting and behavioral redirection.
Document as specifically as possible the client’s behavior
🟪 Documentation is essential but should occur after the unsafe behavior is addressed.
🟪 It does not stop the immediate inappropriate action.
Request an immediate team meeting
🟪 Team collaboration is useful, but not the priority when a real-time boundary must be set.
🟪 Behavior must be addressed directly and immediately before team discussion.
Discuss why the client is making sexual advances
🟪 Exploring motivation is inappropriate in the moment and may reinforce the behavior.
🟪 Insight-oriented discussion is secondary to establishing safety and boundaries.
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This question is from HESI EXIT 2025 Exam.. which contains 126 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: HESI-Exit Exam(s)
- Domain: HESI Exit Exam(s)~2025
- Answer Choices: 4