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?

Verbally de-escalate the client.

Obtain a prescription for haloperidol.

Place the client in restraints.

Take the client to the seclusion room.

Answer and Explanation

The Correct Answer is A

A.   Verbal de-escalation involves using calm, non-confrontational communication techniques to help calm the client. This can include speaking softly, using non-threatening body language, and actively listening to the client's concerns. It is the first-line intervention for managing escalating behavior because it aims to reduce agitation without the use of physical or chemical restraints.
B.   Haloperidol is an antipsychotic medication that may be prescribed for acute agitation and aggression in some situations. However, obtaining a prescription requires provider authorization and should not be the first intervention unless the client's agitation poses an immediate threat to safety and verbal de- escalation has been ineffective. It is typically used when other interventions have not successfully managed agitation.

C.   Physical restraints should only be used as a last resort and in accordance with institutional policies and legal guidelines. Restraints are intended to prevent harm to the client or others when all other methods of de-escalation have failed and there is an imminent risk of harm. Placing a client in restraints without attempting verbal de-escalation first can escalate the situation further.
D.   Seclusion is also a restrictive intervention that should be used judiciously and only when necessary to protect the client or others from harm. It involves placing the client in a designated, secure area where they can be monitored closely. Similar to physical restraints, seclusion should be considered only after attempts at verbal de-escalation have been unsuccessful and there is a clear risk of harm.

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Correct Answer is ["A","C"]

Explanation

A. Individuals with ASPD often exhibit manipulative behaviors to exploit others for their own gain or pleasure. They may be deceitful and use charm or manipulation to achieve their goals.
B. This finding is not typically associated with ASPD. Instead, individuals with ASPD tend to focus on immediate gratification and may have difficulty with long-term planning or sustained attention.
C. People with ASPD typically have a reduced ability to empathize with others. They may disregard the feelings, rights, and sufferings of others, and show little remorse for their actions.
D. Splitting refers to a defense mechanism where individuals tend to view people, situations, or events as either all good or all bad. While this can occur in personality disorders like borderline personality disorder, it is not a characteristic feature of ASPD.
E. Impulsivity is a common trait in individuals with ASPD. They often act without considering the consequences of their actions, leading to risky behaviors such as substance abuse, reckless driving, or criminal activities.

A. "I can encourage my child to think about what they did that allowed this event to happen." B. "I should encourage my child to focus solely on the future." C. "I will have to do all I can to monitor my child's relationships." D. "I anticipate that my child will feel some self-blame."

Correct Answer is D

Explanation

A. This statement suggests a potential for victim-blaming or placing responsibility on the adolescent for the assault. It does not reflect a positive support system because it may contribute to feelings of guilt and shame in the adolescent. Victims of sexual assault should not be made to feel responsible for the actions of the perpetrator.
B. While encouraging the adolescent to focus on the future can be positive, solely focusing on the future without acknowledging or processing the trauma of the assault may invalidate the adolescent's current feelings and experiences. A supportive approach involves acknowledging and validating the adolescent's emotions and experiences, both past and present.
C. This statement may come from a place of concern for the adolescent's safety and well-being, which is understandable. However, it can also indicate a lack of trust or an overprotective stance that may not fully empower the adolescent to regain a sense of control over their life and decisions.
D. This statement demonstrates an understanding of common reactions and emotions experienced by individuals who have been sexually assaulted. Acknowledging that the adolescent may feel self-blame can be a way to open up discussions about these feelings and reassure the adolescent that they are not at fault. It shows empathy and readiness to support the adolescent emotionally.

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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?

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Naxlex Comprehensive Predictor Exams

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