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 ["B","C","D","E"]

Explanation

A. Being married is generally considered a protective factor against suicide. Married individuals often have social support and a sense of belonging, which can reduce suicide risk. Therefore, this would not be identified as a risk factor for suicide.
B. Alcohol use disorder is a significant risk factor for suicide. Alcohol can impair judgment, increase impulsivity, and exacerbate underlying mental health issues. It is associated with higher rates of suicidal ideation and attempts.
C. Family history of suicide, including among siblings, is a known risk factor. Exposure to suicide within the family can contribute to feelings of hopelessness, increase perceived acceptability of suicide, and impact mental health negatively.
D. Access to firearms is a well-established risk factor for completed suicide. Firearms are highly lethal, and their presence increases the likelihood of a fatal suicide attempt compared to other means.
E. Terminal illness, including conditions like terminal liver cancer, can contribute to feelings of hopelessness and despair, potentially increasing suicide risk. The distress related to the prognosis and physical symptoms can exacerbate mental health issues.

A. "You should drink a glass of wine 1 hour before you go to bed." B. "You should take a nap after lunch." C. "You should eat a meal just prior to bedtime." D. "You should limit yourself to two caffeinated beverages per day." E. Correct choice is D

Correct Answer is D

Explanation

A. Consuming alcohol close to bedtime can disrupt sleep patterns. While alcohol may initially induce drowsiness, it often leads to fragmented and poor-quality sleep later in the night. Therefore, advising the client to drink alcohol before bedtime is not recommended.
B. Taking long or late-afternoon naps can interfere with nighttime sleep patterns, especially for individuals experiencing insomnia or sleep disturbances related to depression. Napping can make it harder to fall asleep or stay asleep at night, thereby exacerbating sleep problems rather than improving them.
C. Eating a large or heavy meal just before bedtime can lead to discomfort, indigestion, and even heartburn, which can interfere with falling asleep and staying asleep. It's generally advisable to avoid heavy meals close to bedtime to promote better sleep quality.
D. Caffeine is a stimulant that can interfere with sleep. Consuming caffeinated beverages, especially in the afternoon or evening, can make it difficult for individuals with depression to fall asleep and can contribute to fragmented sleep. Limiting caffeine intake earlier in the day can help promote better sleep hygiene.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

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Correct Answer is D

Explanation

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