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. Voice alteration: Voice alteration is not a typical adverse effect of electroconvulsive therapy (ECT). ECT primarily affects brain function and is not expected to cause changes in vocal function.

B. Neck pain: Neck pain is a potential adverse effect of ECT, particularly related to the positioning of the client during the procedure or muscle stiffness following the seizure induction. It is important to monitor for and address any discomfort or pain experienced by the client.

C. Memory deficit: Memory deficits, particularly short-term memory loss, are common adverse effects of ECT. These deficits are typically temporary and tend to improve over time following completion of the ECT treatment course.

D. Headache: Headache is a potential adverse effect of ECT, particularly following the seizure induction. It may occur due to the physiological effects of the procedure and typically resolves relatively quickly following the completion of the ECT session.

A. Refer the client to a support group for survivors of suicide B. Offer to contact the client’s family or support system C. Inform the client that feelings of guilt are often felt by survivors of suicide D. Determine the clients understanding of the suicide events

Correct Answer is D

Explanation

A. Refer the client to a support group for survivors of suicide: While support groups can be valuable resources for individuals who have lost loved ones to suicide, it may not be the most immediate or appropriate action to take first. The client may not be ready to engage in group support until her immediate needs are addressed.

B. Offer to contact the client’s family or support system: This option demonstrates empathy and practical support by offering assistance in reaching out to the client's family or support system. It can help ensure that the client has immediate emotional support and assistance with practical matters.

C. Inform the client that feelings of guilt are often felt by survivors of suicide: While providing information about common experiences of survivors of suicide can be helpful, it may not be the most immediate action to take first. The client's emotional needs and immediate concerns should be addressed before discussing broader aspects of grief and guilt.

D. Determine the client's understanding of the suicide events: This option involves assessing the client's understanding of the circumstances surrounding the suicide. Understanding the client's immediate thoughts, feelings, and perceptions of the event is essential for providing appropriate support and intervention.

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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 has undergone electroconvulsive therapy (ECT). The nurse should monitor the client for which of the following adverse effects of ECT?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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