A client diagnosed with major neurocognitive disorder is exhibiting behavioral problems daily. At change of shift, the client's behavior escalates from pacing to screaming and waving their arms while on the ground. Which action should be a nursing priority?
Anticipate the behavior and restrain when pacing begins.
Assess environmental triggers and potential unmet needs.
Assess for potential injury.
Consult the psychologist regarding behavior modification techniques.
The Correct Answer is B
a. Anticipate the behavior and restrain when pacing begins: Restraint should be a last resort. Pacing might not necessarily lead to screaming, and early intervention should focus on de-escalation techniques.
b. Assess environmental triggers and potential unmet needs. De-escalation strategies should prioritize understanding why the client's behavior is escalating. Identifying environmental triggers or unmet needs (like pain, hunger, thirst) can help prevent further agitation.
c. Assess for potential injury: While assessing for injury is important, it should come after ensuring the safety of both the client and the staff by addressing the cause of the outburst.
d. Consult the psychologist regarding behavior modification techniques: Consultation is valuable, but immediate intervention to de-escalate the situation and understand the cause is the priority.
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Related Questions
Correct Answer is D
Explanation
a. Focused conversations on various foods: While a healthy relationship with food is a treatment goal, focusing excessively on food during therapy sessions might indicate continued preoccupation, not necessarily a positive change.
b. Is able to binge eat without purging: This might seem positive on the surface, but it doesn't address the underlying problem of binge eating. The goal is to develop healthy eating habits and reduce both bingeing and purging behaviors.
c. Gained ten pounds in one week: Rapid weight gain is unlikely to be a healthy or sustainable outcome in bulimia nervosa treatment. It's important to focus on healthy weight management alongside addressing the core eating disorder behaviors.
d. Demonstrated healthy coping mechanisms that decreased anxiety (Correct): Bulimia nervosa involves recurrent episodes of binge eating followed by purging behaviors. Recovery involves developing healthy coping mechanisms to manage anxiety and reduce the urge to binge or purge. This is a key indicator of progress.
Correct Answer is B
Explanation
a. Psychotic disorder: Schizophrenia is a well-defined psychotic disorder characterized by delusions, hallucinations, and disorganized thinking, but it doesn't specifically address the mood component present in this case.
b. Schizoaffective disorder: Schizoaffective disorder is characterized by symptoms of both schizophrenia (such as delusions and hallucinations) and mood disorders (such as depression or mania). The presence of delusional thinking and visual hallucinations, combined with periods of depression and suicidal ideations, fits the profile of schizoaffective disorder.
c. Paranoid disorder: Paranoid disorder is characterized by a pervasive pattern of suspicion and distrust, but it doesn't necessarily involve hallucinations or disorganized thinking like schizophrenia.
d. Schizophreniform disorder: Schizophreniform disorder is similar to schizophrenia but with a shorter duration of symptoms (less than 6 months). The prompt doesn't specify the duration, making schizophrenia a more likely diagnosis.
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