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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A school-age child wanting to go to summer camp is not at a higher risk for physical abuse.
Choice B rationale:
A toddler with cystic fibrosis is at a higher risk for physical abuse due to the stress and demands of caring for a child with a chronic illness.
Choice C rationale:
An adolescent preparing to leave home for college is not at a higher risk for physical abuse.
Choice D rationale:
A preschooler who is reluctant to share is not at a higher risk for physical abuse.
Correct Answer is B
Explanation
Choice A rationale:
A motor-vehicle crash is an adventitious crisis, not a maturational one.
Choice B rationale:
A child leaving for college is a normal developmental milestone that can cause stress.
Choice C rationale:
Loss of a job is a situational crisis, not a maturational one.
Choice D rationale:
Divorce is a situational crisis, not a maturational one.
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