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    HESI RN Psychiatric and Mental Health Proctored Exam

    An adolescent who was arrested a month ago for gang-related activities has a court order to attend weekly group therapy sessions at the mental health clinic. Today the adolescent's mother calls the clinic nurse to report that her child became angry last night and put a fist through a window. Which intervention is most important for the nurse to implement?

    Explanation & Rationale

    Choice A reason: Reinforcing group therapy attendance is important but does not address the immediate safety risk of the adolescent’s violent behavior. Advising to call the police ensures safety during future violent episodes, making this less urgent and incorrect for managing the acute risk reported by the mother.Choice B reason: Referring the mother for psychiatric evaluation addresses her potential distress but does not mitigate the adolescent’s violent behavior, which poses an immediate safety risk. Advising police contact prioritizes harm prevention, making this incorrect as the most critical intervention for the reported incident.Choice C reason: Advising the mother to call the police if violent behavior recurs ensures safety for the family and adolescent, addressing the immediate risk of harm from punching a window. This intervention aligns with crisis management principles for violent behavior, making it the most important action to implement.Choice D reason: Describing feelings of helplessness to the adolescent may escalate tension and does not address the safety risk of violence. Advising police contact protects the family and ensures intervention for dangerous behavior, making this untherapeutic and incorrect for managing the reported violent incident.

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