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.)
Identify the client's stressors.
Talk to the client using short, simple sentences.
Speak to the client in a loud voice.
Request that security guards restrain the client.
Stand directly in front of the client.
Correct Answer : A,B
Choice A reason: Identifying the client's stressors is a crucial step in managing agitation. Understanding what triggers the client's distress can help the nurse to address the underlying issues and de-escalate the situation.
Choice B reason: Using short, simple sentences can help to communicate effectively with an agitated client. It ensures that the client can process the information without being overwhelmed, which is important for calming the situation.
Choice C reason: Speaking to the client in a loud voice is not recommended as it may escalate the situation. It's important to maintain a calm and soothing tone to avoid further agitation.
Choice D reason: Requesting that security guards restrain the client should be a last resort, only if the client poses an immediate threat to themselves or others. Less restrictive measures should be attempted first.
Choice E reason: Standing directly in front of an agitated client can be perceived as confrontational. It's better to maintain a non-threatening stance and ensure there is enough space to allow the client to feel safe.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While ECT has been used to treat various mental health conditions, its effectiveness in treating borderline personality disorder is not well-established. Borderline personality disorder is typically managed with psychotherapy, and there is limited evidence to support the use of ECT for this condition.
Choice B reason: ECT is not typically used to treat phobias such as a fear of heights. Phobias are usually addressed with cognitive-behavioral therapy and sometimes medication, but not with ECT. Therefore, a decreased fear of heights would not be a typical indicator of ECT's effectiveness.
Choice C reason: ECT may be used in some cases of epilepsy to reduce the frequency of seizures, but it is not a common treatment for this condition. The primary use of ECT is for severe psychiatric conditions, particularly major depressive disorder, and not for neurological disorders like epilepsy.
Choice D reason: ECT is most commonly used to treat severe depression, especially when it is resistant to other treatments. It is known for its rapid and significant improvements in severe symptoms of depression. An improvement in the manifestations of depression, such as a better mood, increased appetite, and improved sleep, is a clear indication that ECT is effective.
Correct Answer is B
Explanation
Choice A reason: Providing a client with a timeline for grieving is not recommended as grief is a highly individual experience and does not follow a set timeline. Each person's journey through grief is unique, and imposing a timeline may invalidate their feelings and hinder the natural process of grieving.
Choice B reason: Encouraging the client to express their feelings is considered a best practice in nursing care for patients with dementia experiencing anticipatory grief. It allows the patient to acknowledge and work through their emotions, which is an important aspect of coping with grief. Open communication can also help the nurse to assess the patient's emotional state and provide appropriate support.
Choice C reason: While showing sympathy can be comforting, it is more beneficial to show empathy. Empathy involves understanding and sharing the feelings of another, which helps in building a stronger connection and providing more personalized care. Sympathy might sometimes be perceived as pity, which can be counterproductive in the therapeutic relationship.
Choice D reason: Sharing personal stories of grief with the client is generally not advised as the focus should remain on the client's experiences. The nurse's role is to facilitate the client's expression of grief, not to shift the focus to their own experiences. Personal stories may also trigger additional stress for the client.
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