A client is upset that the doctor will not increase his pain medication and is now pacing up and down the hall, angrily mumbling to himself. Which nurse will be most successful at de-escalating the client? The nurse who…
Tells the patient their behavior is upsetting the milieu of the unit and asks them to stay in their room
Avoids addressing the behavior, gives PRN pain medication as directed
Listens empathetically to the patient and collaborates with them to manage pain
Calls for the security team to make frequent rounds on the unit
The Correct Answer is C
A: Telling the patient their behavior is upsetting the milieu and asking them to stay in their room may escalate the situation by making the patient feel dismissed and isolated.
B: Avoiding addressing the behavior and giving PRN pain medication without discussing the patient’s concerns does not address the underlying issue and may reinforce the behavior.
C: Listening empathetically to the patient and collaborating with them to manage pain is the most effective approach. It shows the patient that their concerns are being heard and that the nurse is willing to work with them to find a solution, which can help de-escalate the situation.
D: Calling for the security team to make frequent rounds may increase the patient’s agitation and sense of being controlled, which can escalate the situation further.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A: Using seclusion should be a last resort and only used when the patient poses an immediate threat to themselves or others. It is not a proactive strategy for managing frustration.
B: Ensuring the patient understands harsh consequences for violent episodes may not be effective in preventing aggression and can increase feelings of frustration and resentment.
C: Responding to emotional outbursts with negative reinforcement can escalate the situation and is not a therapeutic approach.
D: Creating a quiet and relaxing room provides a safe space for the patient to calm down and manage their emotions. This proactive strategy helps prevent escalation and supports the patient’s ability to cope with frustration
Correct Answer is B
Explanation
A: Impulsivity refers to acting on urges without considering consequences, which is a feature of borderline personality disorder but not the best description of the scenario.
B: Emotional lability, or rapid and intense mood swings, accurately describes the client’s behavior in the scenario.
C: Reaction formation involves behaving in a way that is opposite to one’s true feelings, which is not depicted in the scenario.
D: Splitting involves viewing people or situations as all good or all bad, which can be a feature of borderline personality disorder but is not the primary feature shown in the scenario.
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