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 A

Explanation

Choice A rationale:

Demonstrating a neutral demeanor helps build trust with a client who has paranoid personality disorder. It’s important to avoid showing too much emotion, which could be misinterpreted by the client.

Choice B rationale:

Being vague when answering the client’s questions about instructions could increase the client’s paranoia. Clear and direct communication is essential.

Choice C rationale:

Asking the client why he is suspicious of others could lead to defensive behavior. It’s better to focus on building trust and understanding.

Choice D rationale:

Using an overly friendly approach could be perceived as insincere or manipulative by a client with paranoid personality disorder. A neutral demeanor is more effective.

A. "I'm using a syringe to obtain your blood, not a snake.”. B. "Your provider requires this blood specimen.”. C. "You must be mistaken. D. Snakes cannot be in the clinic.”.

Correct Answer is D

Explanation

(Null)

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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?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is beginning a therapeutic relationship with a client who has paranoid personality disorder. Which of the following strategies should the nurse plan to use?.

Correct Answer is A

Explanation

A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states, "That looks like a snake, and I won't let it take all of my blood.”. Which of the following responses should the nurse make?.

Correct Answer is D

Explanation

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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?.