A nurse is using de-escalation techniques with a client who has become verbally aggressive with a staff member. Which of the following actions should the nurse take?

Remain 15 cm (6 in) away from the client

Use a raised voice when speaking to the chem

Determine the cause of the client's feelings

Ask the client short close-ended question

Answer and Explanation

The Correct Answer is C

A. Remain 15 cm (6 in) away from the client: Maintaining a safe physical distance is important to ensure the safety of both the client and the staff member. However, the specific distance may vary depending on the situation and the client's level of agitation. It's essential to maintain a safe distance while still engaging with the client in a supportive manner.

B. Use a raised voice when speaking to the client: Using a raised voice can escalate the situation further and may increase the client's agitation or aggression. It's important to speak calmly and softly to avoid escalating the situation.

C. Determine the cause of the client's feelings: Understanding the underlying reasons for the client's aggression can help the nurse address the root cause and implement appropriate interventions. It's important to listen actively to the client, validate their feelings, and demonstrate empathy.

D. Ask the client short close-ended questions: Close-ended questions typically elicit simple "yes" or "no" responses and may not encourage open communication or help the client express their feelings. Instead, it's more beneficial to ask open-ended questions that allow the client to express themselves and feel heard.

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Correct Answer is C

Explanation

A. Documentation should occur every 15-30 minutes to ensure the client's safety and to assess the need for continuing or removing the restraints.

B. Keep the client in restraints until the prescription expires: Restraints should be used for the shortest duration necessary to ensure the safety of the client and others. Keeping the client restrained until the prescription expires without reevaluation may not align with best practices for restraint use.

C. Conducting a debriefing with the unit staff is crucial to evaluate the situation, discuss the events leading up to the use of restraints, and develop strategies to prevent the need for future restraint use. This helps ensure the safety and well-being of the client and others, as well as improve care practices.

D.Typically, the evaluation should occur within 1-4 hours depending on the facility's policy and the urgency of the situation.

A. Paranoid B. Histrionic C. Narcissistic D. Antisocial

Correct Answer is B

Explanation

A. Paranoid personality disorder: Individuals with paranoid personality disorder tend to be distrustful, suspicious, and perceive others as malevolent or intending harm. They may exhibit hypervigilance and have difficulty confiding in others.

B. Histrionic personality disorder: Histrionic personality disorder is characterized by excessive emotionality and attention-seeking behavior. Individuals with this disorder may engage in seductive or provocative behavior to gain attention and may display shallow or rapidly shifting emotions.

C. Narcissistic personality disorder: Narcissistic personality disorder is characterized by a pervasive pattern of grandiosity, a need for admiration, and a lack of empathy for others. Individuals with this disorder often have an inflated sense of self-importance and may exploit others to achieve their own goals.

D. Antisocial personality disorder: Antisocial personality disorder is characterized by a disregard for the rights and feelings of others, a lack of empathy or remorse, and a pattern of irresponsible and often criminal behavior. While individuals with antisocial personality disorder may engage in manipulative behaviors, they do so for personal gain rather than seeking attention or admiration.

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A nurse is using de-escalation techniques with a client who has become verbally aggressive with a staff member. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is aggressive toward other clients and has been placed in wrist restraints. After obtaining a prescription for restraints from the provider, which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who exhibits excessive attention-seeking behaviors, including acting flirtatious and seductive. The nurse should identify these behaviors as manifestations of which of the following personality disorders?

Correct Answer is B

Explanation

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A nurse is discharging a client who was admitted for the treatment of alcohol withdrawal. Which of the following resources should the nurse recommend to the client?

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