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 D

Explanation

A. Autonomic dysreflexia: This condition typically occurs in individuals with spinal cord injuries above the T6 level and presents with sudden, severe hypertension, bradycardia, headache, and profuse sweating. It is not typically associated with alcohol withdrawal symptoms such as visual hallucinations and impaired consciousness.

B. Synergistic effect: This term refers to the combined effect of two or more substances or factors being greater than the sum of their individual effects. While alcohol withdrawal can interact with other substances or conditions to produce various effects, it is not a specific condition causing visual hallucinations and impaired consciousness.

C. Sleep deprivation: Prolonged sleep deprivation can lead to cognitive impairment, mood disturbances, and hallucinations, but it is not typically associated with impaired consciousness as described in the scenario. Additionally, the manifestations described are more indicative of alcohol withdrawal rather than sleep deprivation alone.

D. Delirium: Delirium is a state of acute confusion and altered consciousness characterized by disturbances in attention, awareness, cognition, and perception. Visual hallucinations and impaired consciousness are common features of delirium, especially in the context of alcohol withdrawal. Delirium often occurs due to underlying medical conditions, substance withdrawal, or medication side effects.

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

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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