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. This response dismisses the client's experience and hallucination as a mistake. It invalidates the client's feelings and does not acknowledge the client's reality. It can increase the client's distress and undermine trust in the nurse's communication.
B. While this statement provides factual information about the need for the blood specimen, it does not address the client's hallucination or their fear related to it. It may come off as indifferent to the client's feelings and concerns.
C. This option dismisses the client’s feelings without addressing them appropriately.
D. This response validates the client's experience and expresses empathy for their feelings of fear. It acknowledges the hallucination without confirming its reality and shows understanding of how

frightening the experience might be for the client. This response is supportive and helps build trust between the nurse and the client.

A. Manipulative behaviors B. Preoccupation with details C. Lack of empathy D. Splitting E. Impulsiveness

Correct Answer is ["A","C"]

Explanation

A. Individuals with ASPD often exhibit manipulative behaviors to exploit others for their own gain or pleasure. They may be deceitful and use charm or manipulation to achieve their goals.
B. This finding is not typically associated with ASPD. Instead, individuals with ASPD tend to focus on immediate gratification and may have difficulty with long-term planning or sustained attention.
C. People with ASPD typically have a reduced ability to empathize with others. They may disregard the feelings, rights, and sufferings of others, and show little remorse for their actions.
D. Splitting refers to a defense mechanism where individuals tend to view people, situations, or events as either all good or all bad. While this can occur in personality disorders like borderline personality disorder, it is not a characteristic feature of ASPD.
E. Impulsivity is a common trait in individuals with ASPD. They often act without considering the consequences of their actions, leading to risky behaviors such as substance abuse, reckless driving, or criminal activities.

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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 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 D

Explanation

A nurse is collecting data from a client who has antisocial personality disorder. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["A","C"]

Explanation

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A nurse is caring for a client who is receiving treatment for alcohol detoxification. Which of the following medications should the nurse expect to administer during this phase of the client's care?

A nurse in a mental health facility is caring for a client who has antisocial personality disorder and alcohol dependency. The nurse should encourage the client to participate in which of the following groups?

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A nurse is obtaining a health history from a client who reports a recent suicide attempt. Which of the following responses should the nurse make?

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

A nurse is caring for a client who has an anxiety disorder. The client transforms their anxiety into physical manifestations. The nurse should recognize that the client is exhibiting which of the following manifestations?