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. Allowing the client to choose activities may lead to decision fatigue or overwhelm due to the manic state.
B. Initiating physical exercise could help in redirecting excess energy, but it must be carefully monitored.
C. Encouraging the client to spend time with others might increase stimulation and potentially exacerbate the mania.
D. Clarity and specificity in communication are essential when caring for a client experiencing mania. Manic episodes can affect a client's ability to concentrate and process information. Providing clear instructions and explanations helps ensure the client understands what is expected and can follow through with necessary self-care and treatment activities.

A. Assist the clients with establishing long-term goals. B. Ensure the teaching sessions occur right before bedtime. C. Schedule the teaching sessions for a long time to promote participation” D. Use statements rather than "you" statements.

Correct Answer is D

Explanation

A. Helping clients establish long-term goals can provide motivation and direction. However, while setting goals is important, it may not directly address immediate barriers to learning unless the goals are broken down into manageable steps that are relevant to the current learning session.
B. Teaching sessions should not be scheduled right before bedtime because older adults may be fatigued at the end of the day, which can impair their ability to concentrate and retain information. Fatigue can act as a barrier to effective learning.
C. Scheduling teaching sessions for a long duration could lead to cognitive overload and fatigue, which are significant barriers to learning.
D. This can help create a non-threatening learning environment and encourage open communication. This approach can reduce defensiveness and promote a collaborative atmosphere.

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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

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Correct Answer is D

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Correct Answer is D

Explanation

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