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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Leading a group discussion with several clients who have schizophrenia and are dealing with tardive dyskinesia: This activity involves providing support and education to individuals already experiencing a mental health condition and its associated complications. It falls under tertiary prevention, which focuses on minimizing the impact of established disease through treatment and rehabilitation.

B. Screening college students who demonstrate manifestations of depressive disorder: Screening individuals for depressive disorder symptoms, especially in a population known to be at risk (e.g., college students), aims to identify mental health issues early and intervene promptly. This falls under secondary prevention, which involves early detection and treatment to prevent the progression of a condition.

C. Training volunteers in an adult day care facility to communicate effectively with clients who have cognitive impairments: This activity focuses on improving communication and interaction skills with clients who have cognitive impairments. It falls under tertiary prevention, aiming to improve the quality of life and function of individuals already affected by cognitive impairment.

D. Teaching personal coping skills to a group of adults whose parents have Alzheimer's disease: This activity aims to empower individuals with coping skills to manage the stress and challenges associated with having a parent with Alzheimer's disease. It falls under tertiary prevention, focusing on minimizing the negative consequences of an already existing condition.

A. Provide additional attention to the client B. Apply mechanical restraints before administering medication C. Obtain a verbal contract from the client D. Limit staff members who work with the client

Correct Answer is C

Explanation

A. Provide additional attention to the client: While individuals with BPD may crave attention and validation, providing excessive attention can reinforce maladaptive behaviors. Instead, the focus should be on providing consistent and appropriate support while also setting boundaries to encourage healthy coping mechanisms.

B. Apply mechanical restraints before administering medication: Mechanical restraints should only be used as a last resort when less restrictive interventions have failed to ensure the safety of the client and others. Applying restraints before attempting other interventions is not appropriate and may escalate the situation.

C. Obtain a verbal contract from the client: A verbal contract is an agreement between the client and the treatment team regarding safety measures and coping strategies. This intervention involves collaboratively establishing agreements with the client, which can help empower them to take responsibility for their behaviors and engage in treatment planning.

D. Limit staff members who work with the client: Limiting staff members who work with the client may inadvertently isolate the client and hinder the development of therapeutic relationships. Consistency in staffing and a collaborative approach among team members are often more beneficial in providing comprehensive care.

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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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