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 A

Explanation

A. This is a crucial first step in recovery. It involves recognizing and accepting that one has lost control over their drinking and that alcohol use is causing negative consequences in their life. Without acknowledging this lack of control, individuals may not be motivated to seek or engage in treatment.
B. While medications such as disulfiram (Antabuse) or naltrexone (Revia) can be part of a comprehensive treatment plan for alcohol use disorder, agreeing to a prescription for an alcohol use deterrent is not typically the first step in recovery. It usually follows assessment, acknowledgment of the problem, and development of a treatment plan in collaboration with healthcare providers.
C. Building a strong support network is indeed crucial for long-term recovery. This network may include family, friends, peers in recovery, and support groups like Alcoholics Anonymous (AA). However, forming this support network is often a step that occurs as part of ongoing treatment and recovery efforts rather than the very first step.

D. Incorporate a form of spirituality into daily life: Spirituality or a sense of purpose can be a significant component of recovery for some individuals, providing strength and motivation. However, it is not universally considered the first step in recovery. Spirituality may be explored and integrated into the recovery journey as individuals progress in treatment and self-discovery.

A. "A provider may speak to a client's employer regarding a substance use disorder." B. "A client retains the legal right to privacy of health information even after they have died." C. "I can discuss a client's information with staff who have provided care in the past. D. "The provider must give consent to discuss health information with the client's family."

Correct Answer is B

Explanation

A. This statement is incorrect. Under the Health Insurance Portability and Accountability Act (HIPAA) in the United States and similar privacy laws in other countries, healthcare providers are generally prohibited from disclosing a client's health information to their employer without the client's explicit consent.
B. This statement is correct. HIPAA and other privacy laws extend confidentiality protections beyond a client's death. Healthcare providers are still obligated to protect the confidentiality of deceased individuals' health information, unless certain exceptions apply (e.g., public health reasons or legal requirements).
C. Consent from a provider is not sufficient for discussing health information with a client's family; the consent must come from the client or their legal representative.
D. While it is generally good practice to obtain consent from the client before disclosing health information to their family members, there are circumstances where healthcare providers can share information with family members without consent.

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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 substance use disorder clinic is explaining the alcohol recovery process to a client's family. Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is B

Explanation

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