A nurse is caring for a client who becomes extremely agitated. The nurse should document which of the following de-escalation techniques?

Therapeutic hold

Restraint

Diversion

Time-out

Answer and Explanation

The Correct Answer is C

Choice A Reason:
A therapeutic hold is a technique used to safely secure a patient during a procedure or when they are a danger to themselves or others. It is not typically considered a de-escalation technique but rather a response to escalated behavior.

Choice B Reason:
Restraint is a measure used to prevent a patient from causing harm to themselves or others. It is usually a last resort after de-escalation techniques have failed and is not a de-escalation technique itself. Restraint can sometimes escalate the situation further and should be used cautiously.

Choice C Reason:
Diversion, or distraction, is a de-escalation technique that involves redirecting the patient's attention from what is causing their agitation to something less stressful or more positive. This can help calm the patient and prevent the situation from escalating.

Choice D Reason:
Time-out is a strategy where a patient is moved to a separate room to be alone and calm down. While it can be part of a de-escalation strategy, it is not a technique that the nurse would document as having actively employed in the moment of de-escalation.

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Correct Answer is B

Explanation

Choice A Reason

Bradycardia: Bradycardia, or a slower than normal heart rate, is not typically associated with alcohol withdrawal. In fact, alcohol withdrawal is more commonly associated with tachycardia, which is an increased heart rate. This is due to the hyperactivity of the autonomic nervous system as the body reacts to the absence of alcohol. Symptoms like increased heart rate, sweating, and tremors are more indicative of alcohol withdrawal.

Choice B Reason

Double vision: Double vision, or diplopia, can be a symptom of alcohol withdrawal. This occurs due to the effects of alcohol on the central nervous system. When a person stops drinking, the brain and body go through a period of adjustment, which can lead to various neurological symptoms, including double vision. This is part of the broader spectrum of withdrawal symptoms that can include hallucinations and seizures in severe cases.

Choice C Reason

Drowsiness: Drowsiness is not a typical manifestation of alcohol withdrawal. Instead, individuals experiencing withdrawal are more likely to suffer from insomnia, restlessness, and agitation. The withdrawal process often leads to a hyperactive state rather than a sedative one, making drowsiness an unlikely symptom.

Correct Answer is []

Explanation

Potential Condition: Delirium The client’s symptoms such as disorientation to time and place, disorganized thinking, lack of attention, rambling speech, and changes in behavior that began the prior evening suggest the client is most likely experiencing delirium12. Delirium is common in older adults who are postoperative and can be triggered by factors such as dehydration, infection, and certain medications.

Actions to Take:

Choice A: Monitor client’s fluid intake and output The client has refused to eat or drink since the previous day and has a significant difference between intake (250 mL) and output (2,500 mL), suggesting possible dehydration3. Monitoring the client’s fluid intake and output can help assess the client’s hydration status and the effectiveness of interventions such as IV fluid administration.

Choice E: Encourage family members to stay with the client Family members can provide a familiar and reassuring presence, which can help orient the client and potentially reduce agitation and restlessness. They can also provide valuable information about the client’s normal behavior and any changes they have noticed.

Parameters to Monitor:

Choice A: Fall risk The client is attempting to get out of bed without assistance, which increases the risk of falls4. Monitoring the client’s mobility and implementing fall prevention strategies is crucial.

Choice E: Sleep-wake cycle The client has been awake most of the night, indicating a disruption in the sleep-wake cycle5. Monitoring the client’s sleep patterns can provide information about the progression of delirium and the effectiveness of interventions.

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A nurse is caring for a client who becomes extremely agitated. The nurse should document which of the following de-escalation techniques?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is []

Explanation

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