A client is becoming increasingly agitated, anxious, and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?

Verbally de-escalate the client.

Obtain a prescription for haloperidol.

Place the client in restraints.

Take the client to the seclusion room.

Answer and Explanation

The Correct Answer is A

A.   Verbal de-escalation involves using calm, non-confrontational communication techniques to help calm the client. This can include speaking softly, using non-threatening body language, and actively listening to the client's concerns. It is the first-line intervention for managing escalating behavior because it aims to reduce agitation without the use of physical or chemical restraints.
B.   Haloperidol is an antipsychotic medication that may be prescribed for acute agitation and aggression in some situations. However, obtaining a prescription requires provider authorization and should not be the first intervention unless the client's agitation poses an immediate threat to safety and verbal de- escalation has been ineffective. It is typically used when other interventions have not successfully managed agitation.

C.   Physical restraints should only be used as a last resort and in accordance with institutional policies and legal guidelines. Restraints are intended to prevent harm to the client or others when all other methods of de-escalation have failed and there is an imminent risk of harm. Placing a client in restraints without attempting verbal de-escalation first can escalate the situation further.
D.   Seclusion is also a restrictive intervention that should be used judiciously and only when necessary to protect the client or others from harm. It involves placing the client in a designated, secure area where they can be monitored closely. Similar to physical restraints, seclusion should be considered only after attempts at verbal de-escalation have been unsuccessful and there is a clear risk of harm.

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Correct Answer is D

Explanation

A. While medications like SSRIs (Selective Serotonin Reuptake Inhibitors) or benzodiazepines may eventually be part of the treatment plan for OCD, administering medication should not be the first action unless the client is in acute distress or experiencing severe anxiety symptoms that require immediate pharmacological intervention.
B. This option involves assessing the severity of anxiety symptoms, which is important for understanding the client's baseline anxiety level. However, calculating this score is not the first action. It can be done later as part of the comprehensive assessment to guide ongoing treatment planning.
C. Relaxation exercises, such as deep breathing or progressive muscle relaxation, can help manage anxiety symptoms in clients with OCD. However, before initiating specific interventions like relaxation exercises, the nurse should first establish rapport, assess the client's current level of distress, and gather information about the client's symptoms and coping mechanisms.
D. Response prevention is a cognitive-behavioral therapy technique used in the treatment of OCD, where clients are prevented from engaging in compulsive behaviors. This should follow after thorough assessment of the actual psychological state of the client.

A. "I don't understand why you're so upset." B. "Don't worry. You'll feel better soon." C. "Let's discuss what is bothering you." D. "You need to eat to maintain your strength."

Correct Answer is C

Explanation

A. This response may come across as dismissive or lacking empathy. It does not acknowledge the client's feelings or address the underlying concerns contributing to their anxiety. It's important for the nurse to validate the client's emotions and provide reassurance rather than expressing confusion or disbelief.
B. While this response aims to provide reassurance, it may oversimplify the client's feelings and situation. Anxiety is complex, and telling someone not to worry might not be effective in alleviating their distress. It's crucial to engage the client in a more meaningful conversation about their concerns and offer support tailored to their needs.
C. This response demonstrates active listening and therapeutic communication. It encourages the client to express their worries and feelings, which can help them feel understood and supported. By discussing what is bothering them, the nurse can gather important information about the client's concerns and begin to address them effectively.
D. While nutrition is important, this response may come across as directive and could potentially minimize the client's emotional distress. It does not acknowledge the client's anxiety or provide support for their current feelings of restlessness and worry. The nurse should prioritize addressing the client's emotional needs and anxiety before focusing on physical aspects like nutrition.

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A client is becoming increasingly agitated, anxious, and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?

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