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: Meiosis
Meiosis, or the constriction of the pupils, is not typically associated with opioid withdrawal. Instead, opioid withdrawal is characterized by mydriasis, which is the dilation of the pupils. This occurs because the sympathetic nervous system becomes more active when the effects of opioids wear off. Therefore, meiosis is not a manifestation of opioid withdrawal.
Choice B: Hypokinesis
Hypokinesis refers to decreased bodily movement and is not a common symptom of opioid withdrawal. In fact, opioid withdrawal often results in symptoms such as restlessness and agitation, which are the opposite of hypokinesis. Patients may experience increased movement and an inability to stay still due to the discomfort and anxiety associated with withdrawal.
Choice C: Bradycardia
Bradycardia, or a slower than normal heart rate, is not typically seen in opioid withdrawal. Instead, patients undergoing withdrawal are more likely to experience tachycardia, which is an increased heart rate. This is due to the heightened activity of the sympathetic nervous system as the body reacts to the absence of opioids.
Choice D: Diarrhea
Diarrhea is a common symptom of opioid withdrawal. Opioids often cause constipation by slowing down the gastrointestinal tract. When the opioids are discontinued, the gastrointestinal system becomes overactive, leading to diarrhea. This is a well-documented and expected manifestation of opioid withdrawal.
Correct Answer is ["2.5"]
Explanation
Step 1: Determine the total dosage required.
50 mg
Step 2: Determine the concentration of the solution.
20 mg/mL
Step 3: Calculate the volume needed.
50 mg ÷ 20 mg/mL = 2.5 mL
The nurse should administer 2.5 mL.
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