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. Bradycardia (slow heart rate) is not typically associated with alcohol withdrawal. Instead, tachycardia (rapid heart rate) is more commonly observed due to the stimulant effects of alcohol withdrawal on the autonomic nervous system.
B. Drowsiness is not a common symptom of alcohol withdrawal. Instead, individuals may experience insomnia or disturbed sleep patterns as part of withdrawal symptoms.
C. Double vision (diplopia) is not a typical finding in alcohol withdrawal.
D. When a person stops or significantly decreases their alcohol intake after long-term use, the body can react with symptoms like increased blood pressure.

A. Diarrhea B. Meiosis C. Bradycardia D. Hypokinesis

Correct Answer is A

Explanation

A. Diarrhea is a common symptom of opioid withdrawal. Opioids slow down gastrointestinal motility, so when their use is discontinued, it can lead to increased peristalsis and diarrhea. This occurs due to the rebound effect of the gastrointestinal tract.
B. Opioids typically cause pupil constriction (pinpoint pupils) when they are active in the body. During withdrawal, the opposite occurs, and pupils dilate (mydriasis). However, the question asks about withdrawal symptoms, not effects of opioid use, so this would not be expected in opioid withdrawal.
C. Bradycardia, or a slow heart rate, is not typically associated with opioid withdrawal. Instead, opioid withdrawal can cause tachycardia (rapid heart rate) due to the sympathetic nervous system activation that occurs during withdrawal.
D. Hypokinesis refers to decreased movement or activity, which is not a typical symptom of opioid withdrawal. Instead, opioid withdrawal often presents with symptoms such as restlessness, agitation, and muscle aches, which are indicative of hyperactivity rather than hypokinesis.

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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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Correct Answer is D

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Correct Answer is A

Explanation

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