A client is becoming increasingly agitated, anxious, and tense.
The nurse notes a clenched jaw and a change in the pitch of the client's voice.
Which of the following interventions should the nurse implement first?.

Obtain a prescription for haloperidol.

Take the client to the seclusion room.

Verbally de-escalate the client.

Place the client in restraints.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Obtaining a prescription for haloperidol is not the first intervention the nurse should implement. Medication should be considered only after non-pharmacological interventions have been attempted.

Choice B rationale:

Taking the client to the seclusion room is not the first intervention the nurse should implement. Seclusion should be used only as a last resort when all other interventions have failed and the client is a danger to themselves or others.

Choice C rationale:

Verbally de-escalating the client is the first intervention the nurse should implement. This involves using calm, clear communication to help the client regain control of their emotions.

Choice D rationale:

Placing the client in restraints is not the first intervention the nurse should implement. Restraints should be used only as a last resort when all other interventions have failed and the client is a danger to themselves or others.

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Correct Answer is D

Explanation

Choice A rationale:

Alcohol can interfere with sleep patterns and should not be used as a sleep aid.

Choice B rationale:

Napping can make it harder to fall asleep at night.

Choice C rationale:

Eating just before bedtime can cause discomfort and disrupt sleep.

Choice D rationale:

Limiting caffeine intake can help improve sleep, as caffeine is a stimulant that can interfere with the ability to fall asleep.

A. "Everyone feels depressed during the grieving process.”. B. "You should start participating in your usual activities.”. C. "I remember how depressed I was after my friend died.”. D. "Tell me what your relationship with your partner was like.”.

Correct Answer is D

Explanation

Choice A rationale:

This statement is generalizing the client’s feelings, which can lead to a lack of individualized care.

Choice B rationale:

This statement is not acknowledging the client’s feelings of grief, which can lead to a lack of trust in the nurse-client relationship.

Choice C rationale:

This statement is self-disclosing personal information, which can lead to boundary violations in the nurse-client relationship.

Choice D rationale:

This statement is encouraging the client to express their feelings, which can help in the grieving process.

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A client is becoming increasingly agitated, anxious, and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?.

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A client is becoming increasingly agitated, anxious, and tense.
The nurse notes a clenched jaw and a change in the pitch of the client's voice.
Which of the following interventions should the nurse implement first?.