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 {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
Choice A: Vital Signs The client’s vital signs show a decrease in temperature, respiratory rate, pulse rate, and blood pressure. This could indicate a potential worsening condition as the drop in blood pressure and pulse rate could suggest dehydration or shock, especially given the client’s history of water toxicity.
Choice B: Mucous Membranes The client’s mucous membranes are pale and dry. This could be a sign of dehydration, which would indicate a potentially worsening condition.
Choice C: Vision The client reports blurred vision. This could be a symptom of various conditions, including side effects of medications, glaucoma, or neurological disorders, indicating a potential worsening condition.
Choice D: Lithium Level The client’s lithium level decreased from 1.8 mEq/L to 1.2 mEq/L. This could indicate an improvement as the lithium level is now within the normal range (less than 1.5 mEq/L). However, it’s important to monitor the client’s symptoms as lithium is used to treat bipolar disorder.
Choice E: Urine Output The client’s urine output is 40 mL/hr. This is within the normal range for adults, indicating a potential improvement. However, it’s important to monitor this closely as changes in urine output can be a sign of kidney problems.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A Reason:
Lack of empathy is a hallmark symptom of antisocial personality disorder. Individuals with this condition often have difficulty understanding or sharing the feelings of others, which can lead to a disregard for the rights and feelings of others.
Choice B Reason:
Manipulative behaviors are common in those with antisocial personality disorder. They may use charm, wit, or deceit to manipulate others for personal gain or pleasure.
Choice C Reason:
Splitting is not typically listed as a symptom of antisocial personality disorder. However, it is a defense mechanism where an individual views others as either all good or all bad, which can be seen in various personality disorders, including antisocial personality disorder.
Choice D Reason:
Preoccupation with details is not a characteristic of antisocial personality disorder. It is more commonly associated with obsessive-compulsive personality disorder, where there is an excessive focus on orderliness and perfectionism.
Choice E Reason:
Impulsiveness is another core feature of antisocial personality disorder. Individuals may act on the spur of the moment without considering the consequences, leading to risky behaviors.
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