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 A

Explanation

A. This response encourages the client to express their feelings and memories about their relationship with their deceased partner. It allows the client to talk about their emotions, reminisce about positive memories, and potentially share any unresolved issues or feelings of loss. This can be therapeutic as it provides an opportunity for the client to process their grief through storytelling and expression.
B. This response shifts the focus from the client's experience to the nurse's own experience. It can detract from the client's need to talk about their own feelings and may not be perceived as empathetic. While sharing personal experiences can sometimes create rapport, in this context, it may not be the most therapeutic approach as it might minimize the client's unique experience and emotions.
C. This response assumes a directive approach, suggesting what the client "should" do. While encouraging a return to routine activities can be beneficial in some cases, it may not be appropriate immediately after a significant loss. Grieving is a personal process, and the client may not be ready to engage in usual activities right away. It's important to assess the client's readiness and provide support tailored to their current emotional state.
D. This response minimizes the client's feelings by suggesting that their experience is universal. While it's true that many people experience sadness and grief after a loss, each individual's response is unique. This statement may invalidate the client's emotions and fail to acknowledge the depth of their distress. It's important to validate the client's feelings and provide reassurance that their emotions are normal in the context of grief.

A. Place the client in a room close to the nurses' station. B. Request a consult with recreational therapy. C. Lower the window shade in the client's room. D. Obtain a PRN prescription for a vest restraint.

Correct Answer is A

Explanation

A. This is a proactive measure to enhance supervision and quick response to any signs of agitation, wandering, or attempts to get out of bed without assistance. Being closer to the nurses' station allows for more frequent monitoring and timely intervention to prevent falls.
B. Recreational therapy can play a significant role in enhancing the client's physical and cognitive abilities through tailored activities. Activities such as balance exercises, supervised walks, or engaging in structured programs can help improve mobility and reduce the risk of falls.
C. Lowering the window shade can reduce distractions and provide a calmer environment for the client. Excessive light or glare can sometimes contribute to confusion or disorientation in individuals with dementia. A more subdued environment can potentially decrease agitation and wandering behaviors, indirectly lowering the risk of falls.

D. The use of physical restraints, such as vest restraints, is generally discouraged in clients with dementia due to the potential for physical and psychological harm. Restraints can increase agitation, anxiety, and risk of injury, and they do not address the underlying causes of falls. The focus should be on environmental modifications, supervision, and non-pharmacological interventions.

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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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