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

Explanation

A. Cognitive behavioral therapy (CBT) is a commonly used psychotherapy approach for bipolar disorder. Attending a CBT class typically does not require specific informed consent beyond the general consent for treatment, as it involves non-invasive, non-experimental therapeutic techniques aimed at improving coping skills and managing symptoms. In most cases, attending therapy sessions like CBT is considered part of routine care for mental health conditions.
B. Experimental medications involve drugs or treatments that are not yet approved by regulatory agencies (such as the FDA in the United States) for general use. For a client to participate in a clinical trial or receive an experimental medication, they must provide explicit informed consent after being informed about the potential risks, benefits, and uncertainties associated with the treatment. This process ensures that the client understands they are participating in research and not receiving standard care.
C. Participating in a group exercise program is generally considered a routine therapeutic intervention aimed at promoting physical health and well-being. While informed consent is important for all interventions, including exercise programs, it typically involves providing general information about the program's goals, activities, and any potential risks. Clients are not consenting to experimental treatments or procedures that go beyond standard exercise protocols.

D. Light therapy, also known as phototherapy, is a treatment often used for seasonal affective disorder (SAD) and other mood disorders. It involves exposure to specific wavelengths of light to regulate circadian rhythms and improve mood. While light therapy is a specialized treatment, it is a standard intervention for mood disorders and does not typically require separate informed consent beyond what is provided for standard medical treatments.

A. Risperidone B. Bupropion C. Aripiprazole D. Quetiapine

Correct Answer is B

Explanation

A. Risperidone is an antipsychotic medication used to treat conditions like schizophrenia and bipolar disorder. It is not indicated for smoking cessation and does not have any direct effect on nicotine withdrawal or cravings. Therefore, it would not be included in discussions about smoking cessation medications.
B. Bupropion is a medication that is FDA-approved for smoking cessation. It works by reducing nicotine cravings and withdrawal symptoms. It is available in sustained-release formulations specifically marketed for smoking cessation under the brand name Zyban. Bupropion can be effective in helping individuals quit smoking and is often recommended as a first-line treatment.
C. Aripiprazole is an antipsychotic medication used primarily to treat conditions such as schizophrenia, bipolar disorder, and major depressive disorder. It does not have any specific indication or role in smoking cessation. Therefore, it would not typically be included in discussions about medications for quitting smoking.
D. Quetiapine is another antipsychotic medication used to treat conditions like schizophrenia, bipolar disorder, and major depressive disorder. Similar to aripiprazole and risperidone, it does not have any direct role in smoking cessation. It is not indicated for reducing nicotine cravings or aiding in smoking cessation efforts.

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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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