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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D"]
Explanation
a. Blood pressure 110/70: This is within normal range for many individuals and is not immediately concerning in the post-operative context.
b. heart rate 86: This is a normal heart rate for most individuals and is not concerning post-operatively.
c. Hypoactive bowel sounds: Hypoactive bowel sounds are common post-operatively due to anesthesia and are not immediately concerning.
d. Increased restlessness Increased restlessness can be a sign of pain, anxiety, hypoxia, or other complications and should be addressed promptly.
e. Negative Homan's sign: A negative Homan’s sign indicates no apparent deep vein thrombosis and is a positive finding.
Correct Answer is D
Explanation
a. "I know I can't use physical force anymore, but I can intimidate someone with my words." This indicates that the client still considers using intimidation, which is not a healthy way of managing anger or aggression.
b. "Because my wife seems to be the one to set me off, I've decided never to see her again." Avoiding a trigger rather than managing the response to it does not indicate progress in anger and aggression management.
c. "It's bad to feel as angry as I feel. I'm working on eliminating this evil feeling completely." Viewing anger as entirely negative and trying to eliminate it rather than managing it constructively does not show effective anger management.
d. "I realize I have a problem expressing my anger appropriately." This is correct because recognizing and admitting the problem is a critical first step toward making meaningful changes in managing anger and aggression.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
