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","C","D","E"]
Explanation
Choice A rationale:
Diarrhea is not typically associated with anorexia nervosa. Constipation is more common due to reduced food intake.
Choice B rationale:
Hypotension can occur in anorexia nervosa due to decreased circulating blood volume from inadequate fluid and food intake.
Choice C rationale:
Cold extremities can be a sign of anorexia nervosa due to the body’s attempt to conserve heat in response to inadequate caloric intake.
Choice D rationale:
Tooth erosion can occur in anorexia nervosa due to frequent vomiting, which exposes the teeth to stomach acid.
Choice E rationale:
Lanugo, or fine body hair, can develop in anorexia nervosa as the body’s attempt to insulate itself due to loss of body fat.
Correct Answer is C
Explanation
Choice A rationale:
Absence of impulsive behaviors is not a risk factor for becoming a perpetrator of child abuse. Impulsive behaviors can lead to unpredictable and potentially harmful actions, but their absence does not increase the risk of abusive behavior.
Choice B rationale:
Being involved in community activities is generally a positive factor and does not increase the risk of becoming a perpetrator of child abuse. It can provide a support network and positive role models, which can help prevent abusive behaviors.
Choice C rationale:
Low tolerance for frustration is a risk factor for becoming a perpetrator of child abuse. Frustration can lead to anger and potentially harmful actions, especially if the person does not have effective coping mechanisms.
Choice D rationale:
A submissive personality is not a risk factor for becoming a perpetrator of child abuse. While it may affect interpersonal relationships, it does not directly increase the risk of abusive behavior.
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