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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Haloperidol is not commonly associated with causing ringing in the ears (tinnitus). While tinnitus can be a side effect of some medications, it is not typically linked to haloperidol.
Choice B reason:
Urinary incontinence is not a common side effect of haloperidol. This medication is more likely to cause urinary retention rather than incontinence.
Choice C reason:
Experiencing a metallic taste is not a known side effect of haloperidol. This side effect is more commonly associated with other medications, such as certain antibiotics or chemotherapy drugs.
Choice D reason:
Increased sensitivity to the sun (photosensitivity) is a known side effect of haloperidol. Clients taking this medication should be advised to use sun protection and avoid prolonged sun exposure.
Correct Answer is C
Explanation
Choice A Reason:
Eating a meal just before bedtime is generally not recommended for promoting sleep. Consuming food late at night can lead to indigestion and discomfort, which can interfere with the ability to fall asleep and stay asleep. Additionally, certain foods may cause an increase in energy levels, making it harder to wind down. The body’s digestive process can also disrupt the natural sleep cycle, leading to poorer sleep quality.
Choice B Reason:
Drinking a glass of wine or any alcoholic beverage before bed is not advisable for promoting healthy sleep. While alcohol might initially make you feel drowsy, it can disrupt the sleep cycle later in the night. Alcohol can interfere with the REM (Rapid Eye Movement) stage of sleep, which is crucial for restorative sleep. It can also lead to fragmented sleep and frequent awakenings, reducing overall sleep quality.
Choice C Reason:
Limiting caffeine intake is a well-known strategy for improving sleep quality. Caffeine is a stimulant that can interfere with the ability to fall asleep and stay asleep. By limiting yourself to two caffeinated beverages per day, preferably consumed earlier in the day, you reduce the likelihood of caffeine affecting your sleep. This recommendation aligns with sleep hygiene practices that promote better sleep patterns and overall sleep quality.
Choice D Reason:
Taking a nap after lunch can be beneficial for some people, but it can also interfere with nighttime sleep if not managed properly. Long or late naps can reduce the body’s sleep drive, making it harder to fall asleep at night. For individuals with sleep difficulties, it is often recommended to avoid napping or to limit naps to short durations (20-30 minutes) and to take them earlier in the day to prevent interference with nighttime sleep.
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