A client diagnosed with major neurocognitive disorder is exhibiting behavioral problems daily. At change of shift, the client's behavior escalates from pacing to screaming and waving their arms while on the ground. Which action should be a nursing priority?
Anticipate the behavior and restrain when pacing begins.
Assess environmental triggers and potential unmet needs.
Assess for potential injury.
Consult the psychologist regarding behavior modification techniques.
The Correct Answer is B
a. Anticipate the behavior and restrain when pacing begins: Restraint should be a last resort. Pacing might not necessarily lead to screaming, and early intervention should focus on de-escalation techniques.
b. Assess environmental triggers and potential unmet needs. De-escalation strategies should prioritize understanding why the client's behavior is escalating. Identifying environmental triggers or unmet needs (like pain, hunger, thirst) can help prevent further agitation.
c. Assess for potential injury: While assessing for injury is important, it should come after ensuring the safety of both the client and the staff by addressing the cause of the outburst.
d. Consult the psychologist regarding behavior modification techniques: Consultation is valuable, but immediate intervention to de-escalate the situation and understand the cause is the priority.
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Related Questions
Correct Answer is A
Explanation
a. fluoxetine: Fluoxetine, a selective serotonin reuptake inhibitor (SSRI), has been used with some success in treating anorexia nervosa, especially when comorbid with depression. It can help with mood stabilization and reducing obsessive-compulsive behaviors related to food.
b. sibutramine: Sibutramine was an appetite suppressant used for weight loss, but it has been withdrawn from the market in many countries due to cardiovascular risks. It is not used for treating anorexia nervosa.
c. carbamazepine; Carbamazepine is an anticonvulsant and mood stabilizer, primarily used for bipolar disorder and seizure disorders. It is not commonly used for anorexia nervosa.
d. diazepam: Diazepam is a benzodiazepine used primarily for anxiety, muscle spasms, and seizures. It does not have a primary role in the treatment of anorexia nervosa and depression.
Correct Answer is C
Explanation
a. refuses to eat lunch. Refusal to eat lunch might indicate displeasure or upset but does not directly suggest escalating aggression.
b. requests prn medications. Requesting prn (as needed) medications typically indicates the client is aware of their distress and is seeking help, not escalating aggression.
c. is pacing around the milieu. Pacing can be a sign of increasing agitation and is often observed in clients who are escalating towards aggressive behavior. This physical activity can indicate restlessness and an inability to calm down.
d. sits in a group with their peers. Sitting in a group with peers suggests a level of social engagement and does not indicate escalating aggression.
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