A nurse is caring for a client who becomes extremely agitated and asks if they can go to a separate room to be alone for an hour. The nurse should document which of the following de- escalation techniques in the client's medical record?

Timeout

Restraint

Diversion

Therapeutic hold

Answer and Explanation

The Correct Answer is A

A.   This technique involves allowing the client to remove themselves from the situation causing agitation temporarily. It is a de-escalation technique where the client can regain composure and reduce agitation by being alone or in a quieter environment. The nurse ensures the environment is safe and monitors the client during this time.
B.   Restraint involves physically restricting the client's movement to prevent harm to themselves or others when they are in a state of extreme agitation and are at risk of causing harm. It is used as a last resort and typically requires a healthcare provider's order due to the potential risks and ethical considerations.
C.   Diversion involves redirecting the client's attention away from the source of agitation to something else, such as a calming activity or a change of topic. It can help shift the client's focus and reduce escalating emotions.
D.   Also known as a therapeutic restraint hold, this technique is used to safely manage a client who is agitated and may become physically aggressive. It involves trained staff using specific holds to restrain the client in a way that prevents harm while allowing for therapeutic communication.

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Correct Answer is D

Explanation

A. Lanugo refers to fine, soft hair that grows on the face, back, and arms as a result of malnutrition. It is more common in anorexia nervosa rather than bulimia nervosa.
B. Muscle wasting is not typically a primary symptom of bulimia.
C. Hypomagnesemia, or low magnesium levels, may occur but is not very characteristic of bulimia nervosa.
D. Hypokalemia, or low levels of potassium in the blood, is a common finding in individuals with bulimia nervosa who engage in purging behaviors such as vomiting or misuse of diuretics. Potassium is crucial for proper muscle and nerve function, and low levels can lead to symptoms such as muscle weakness, fatigue, cardiac arrhythmias, and in severe cases, paralysis.

A. Providing opportunities for nutrition and toileting B. Observing range of motion of client's extremities C. Observation of the client once per hour D. Attempts at less restrictive interventions E. Names of staff members caring for the client

Correct Answer is ["A","B","D","E"]

Explanation

A. It is essential to document the times when the client was offered opportunities for nutrition and toileting while in restraints. This includes offering food and fluids at regular intervals and assisting the client with toileting needs as required. Documentation ensures that these basic needs are met despite the restraint status.
B. Documenting observations of the client's range of motion helps monitor for any signs of discomfort, circulation issues, or injury related to being in restraints. This documentation is crucial for ensuring the client's safety and well-being during restraint use.
C. observation of the client should be conducted more frequently than once per hour, especially after an episode of violence, to closely monitor the client's condition and response to the restraints.
D. Documenting attempts at less restrictive interventions shows that the healthcare team is actively working to minimize the use of restraints whenever possible. This might include attempts to de-escalate the client, use of medications, or other interventions aimed at reducing agitation or violence without resorting to physical restraints.
E. It is important to document the names of staff members who are directly involved in the care of a restrained client. This ensures accountability and provides a clear record of who has been caring for the client during their restraint period.

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A nurse is caring for a client who becomes extremely agitated and asks if they can go to a separate room to be alone for an hour. The nurse should document which of the following de- escalation techniques in the client's medical record?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is assisting in the care of a client who is in restraints following an episode of violence. Which of the following information should the nurse document in the client's medical record? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

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