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.

Take the client to the seclusion room.

Place the client in restraints.

Obtain a prescription for haloperidol.

Answer and Explanation

The Correct Answer is A

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Correct Answer is B

Explanation

Choice A rationale

Making a unit calendar helps with orientation but doesn't specifically engage reminiscence therapy, which focuses on recalling past experiences.

Choice B rationale

Discussing childhood memories fosters reminiscence, aiding in cognitive stimulation and emotional connection among older adults.

Choice C rationale

Thought-stopping techniques are more suited for managing negative thoughts in disorders like anxiety or depression, not for reminiscence therapy.

Choice D rationale

Playing board games enhances cognition but doesn't specifically target reminiscence, which involves sharing and discussing past experiences.

A. I don't see a snake, but that must be scary for you. B. I'm using a syringe to obtain your blood, not a snake. C. Your provider requires this blood specimen. D. You must be mistaken.

Correct Answer is A

Explanation

Choice A rationale

Acknowledging the client's fear and providing reassurance without confirming the hallucination helps build trust and reduce anxiety.

Choice B rationale

Correcting the client by stating it is a syringe, not a snake, dismisses their fear and can increase distress.

Choice C rationale

Emphasizing the provider's requirement for the blood specimen does not address the client's fear and can worsen anxiety.

Choice D rationale

Telling the client they are mistaken dismisses their hallucination and can increase their distress and mistrust.

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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

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A nurse is assisting with reminiscence therapy for a group of older adult clients.Which of the following strategies should the nurse implement?

Correct Answer is B

Explanation

A nurse in a mental health facility is collecting a blood specimen from a client.The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood.”. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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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?