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
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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Related Questions
Correct Answer is C
Explanation
A. This response may come across as dismissive or lacking empathy. It does not acknowledge the client's feelings or address the underlying concerns contributing to their anxiety. It's important for the nurse to validate the client's emotions and provide reassurance rather than expressing confusion or disbelief.
B. While this response aims to provide reassurance, it may oversimplify the client's feelings and situation. Anxiety is complex, and telling someone not to worry might not be effective in alleviating their distress. It's crucial to engage the client in a more meaningful conversation about their concerns and offer support tailored to their needs.
C. This response demonstrates active listening and therapeutic communication. It encourages the client to express their worries and feelings, which can help them feel understood and supported. By discussing what is bothering them, the nurse can gather important information about the client's concerns and begin to address them effectively.
D. While nutrition is important, this response may come across as directive and could potentially minimize the client's emotional distress. It does not acknowledge the client's anxiety or provide support for their current feelings of restlessness and worry. The nurse should prioritize addressing the client's emotional needs and anxiety before focusing on physical aspects like nutrition.
Correct Answer is D
Explanation
A. This scenario involves the issue of informed consent and medical ethics rather than libel. It pertains to the client's right to make decisions about their treatment. While administering medication without consent could have legal and ethical implications, it does not relate to libel.
B. This is an example of negligence or breach of duty, which could result in harm to the client. It pertains to safety protocols and standards of care rather than libel. Properly securing a client in a wheelchair is crucial for their safety and is not related to libel.
C. This example involves ethical considerations around coercion and restraint use. Threatening to apply restraints without a legitimate reason or following proper protocols could be considered a violation of
the client's rights. However, it does not constitute libel, as it does not involve false statements that harm someone's reputation through written or broadcasted communication.
D. This is an example of libel. Documenting false information about a client's substance use history can damage their reputation and potentially lead to negative consequences for the client, such as improper treatment or legal ramifications. Accurate and truthful documentation is essential in healthcare to ensure proper care and respect for the client's rights.
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