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 D

Explanation

A. Role-playing is a useful technique to teach and reinforce new behaviors by allowing the child to practice appropriate responses in simulated situations. While role-playing can be beneficial, it is not specifically related to redirection technique. Redirection involves diverting a child's attention or behavior away from inappropriate or disruptive actions towards more acceptable behaviors.
B. Moving closer to a child who is agitated can be a strategy to provide physical proximity and support, especially to prevent escalation of behavior or to intervene if necessary. However, it is not directly related to redirection technique.
C. Ignoring attention-seeking behaviors is a common behavior management strategy aimed at reducing reinforcement of undesirable behaviors. While ignoring can be effective in some situations, it is not specifically redirection technique.
D. This statement correctly reflects the redirection technique. Redirection involves redirecting the child's focus or behavior from negative or inappropriate actions towards positive and appropriate activities or tasks. By re-engaging the child in an appropriate activity, the parent can effectively redirect their attention and energy, potentially preventing or diffusing disruptive behaviors.

A. Submissive personality B. Involved in community activities C. Low tolerance for frustration D. Absence of impulsive behaviors

Correct Answer is C

Explanation

A. A submissive personality alone is less likely to be a direct risk factor for becoming a perpetrator of child abuse. Individuals with a submissive personality tend to avoid confrontation and conflict rather than engage in aggressive or abusive behaviors towards others.
B. Being involved in community activities is generally a positive factor that promotes social engagement, support networks, and a sense of belonging. It does not inherently contribute to an increased risk of becoming a perpetrator of child abuse.
C. Low tolerance for frustration can be a risk factor for potential aggressive or impulsive behaviors. When individuals have difficulty managing frustration, they may be more prone to react impulsively or aggressively towards others, including children.

D. The absence of impulsive behaviors typically indicates better impulse control and decision-making abilities. Individuals who can regulate their impulses are less likely to engage in spontaneous or aggressive actions, including perpetrating child abuse.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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