A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply)
Speak to the client in a loud voice
Stand directly in front of the client
Request that security guards restrain the client
Talk to the client using short, simple sentences
Identify the client’s stressors
The Correct Answer is D
Choice A reason: Speaking loudly escalates tension in an agitated client, mimicking confrontation and potentially worsening yelling or pacing. De-escalation requires a calm, low tone to soothe, not provoke. This action contradicts mental health principles for managing agitation, increasing risk, so it’s not appropriate here.
Choice B reason: Standing directly in front risks invading personal space, heightening agitation in a yelling, pacing client, possibly triggering aggression. A side approach maintains safety and openness, per de-escalation guidelines. This position endangers the nurse and client, making it an incorrect choice.
Choice C reason: Requesting restraints assumes immediate danger without de-escalation attempts, violating least restrictive care. Yelling and pacing alone don’t justify physical control unless harm is imminent. This premature escalation skips verbal intervention, so it’s not suitable unless safety fails.
Choice D reason: Short, simple sentences calm the client by reducing cognitive overload during agitation, facilitating understanding amid yelling and pacing. This de-escalation technique, part of crisis management, promotes cooperation safely. It’s a primary, effective step, making it a correct action here.
Choice E reason: Identifying stressors uncovers agitation triggers (e.g., fear, pain), guiding tailored de-escalation for a yelling, pacing client. This insight informs interventions, reducing escalation risk in mental health settings. It’s a proactive, therapeutic step, correctly included in the nurse’s response.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Hospice care applies to terminal stages (6 months or less), not a newly diagnosed Alzheimer’s client, who may live years. It’s end-of-life support, not a treatment to alter disease progression. This option is premature and irrelevant to early management, so it’s incorrect.
Choice B reason: Transcranial magnetic stimulation treats depression, not Alzheimer’s cognitive decline directly. It stimulates brain activity but lacks evidence for improving memory or cognition in this disease. This experimental approach doesn’t fit standard care, making it an unsuitable teaching point.
Choice C reason: Barbiturates sedate for seizures or anesthesia, not anxiety in Alzheimer’s, risking dependency and worsening cognition. Benzodiazepines are preferred if needed, but neither is a core treatment. This outdated, risky option doesn’t address the disease, so it’s not appropriate.
Choice D reason: NMDA receptor agonists like memantine slow cognitive decline in Alzheimer’s by regulating glutamate, reducing excitotoxicity. This FDA-approved treatment delays memory loss, a key teaching point for new diagnoses. It aligns with disease management, making it the correct choice.
Correct Answer is B
Explanation
Choice A reason: Schema-focused therapy targets deep beliefs, often for borderline personality, not narcissistic traits like grandiosity. It’s less tailored to NPD’s need for self-esteem regulation and empathy building. Evidence for NPD is limited, making it less suitable than CBT for this client.
Choice B reason: Cognitive behavioral therapy (CBT) addresses distorted thinking and behaviors in NPD, like entitlement, fostering realistic self-view and empathy. It’s evidence-based for personality disorders, adaptable to grandiosity and interpersonal issues. This aligns with NPD treatment goals, making it the recommended choice.
Choice C reason: Assertiveness training enhances communication but doesn’t tackle NPD’s core—lack of empathy or inflated self-image. It may reinforce dominance, not humility, unhelpful for this disorder. This superficial approach lacks depth for personality change, so it’s not ideal.
Choice D reason: Response prevention therapy suits OCD, preventing compulsions, not NPD’s interpersonal or ego issues. It’s irrelevant to narcissistic traits like arrogance or validation-seeking. This mismatch with the disorder’s needs makes it an incorrect treatment option here.
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