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","B","D","E"]

Explanation

A. It is essential to document the times when the client was offered opportunities for nutrition and toileting while in restraints. This includes offering food and fluids at regular intervals and assisting the client with toileting needs as required. Documentation ensures that these basic needs are met despite the restraint status.
B. Documenting observations of the client's range of motion helps monitor for any signs of discomfort, circulation issues, or injury related to being in restraints. This documentation is crucial for ensuring the client's safety and well-being during restraint use.
C. observation of the client should be conducted more frequently than once per hour, especially after an episode of violence, to closely monitor the client's condition and response to the restraints.
D. Documenting attempts at less restrictive interventions shows that the healthcare team is actively working to minimize the use of restraints whenever possible. This might include attempts to de-escalate the client, use of medications, or other interventions aimed at reducing agitation or violence without resorting to physical restraints.
E. It is important to document the names of staff members who are directly involved in the care of a restrained client. This ensures accountability and provides a clear record of who has been caring for the client during their restraint period.

A. Dual diagnosis treatment B. Codependency support C. Psychodrama D. Crisis intervention

Correct Answer is A

Explanation

A. Dual diagnosis treatment programs are specifically designed for individuals who have both a mental health disorder (such as ASPD) and a substance use disorder (alcohol dependency in this case). These programs integrate treatment approaches that address both conditions concurrently. They typically involve a combination of medication management, psychotherapy, and support groups tailored to dual diagnosis clients. Encouraging the client to participate in a dual diagnosis treatment group can help address the complex interplay between ASPD and alcohol dependency.
B. Codependency support groups focus on relationships where one person may enable or support dysfunctional behavior in another person. While relevant in certain contexts, codependency support groups may not directly address the primary issues of ASPD and alcohol dependency. Therefore, this option is less appropriate compared to dual diagnosis treatment for this client.
C. Psychodrama is a form of therapy where clients act out real-life situations to explore and gain insights into their feelings, behaviors, and relationships. While psychodrama can be beneficial for emotional expression and role-playing, it may not directly target the core symptoms and challenges of ASPD and alcohol dependency. Therefore, it may not be the most effective intervention for this client compared to dual diagnosis treatment.
D. Crisis intervention focuses on immediate stabilization and support during a mental health crisis or acute episode. While crisis intervention may be necessary at times, it is not a comprehensive treatment approach for ASPD and alcohol dependency. Long-term management and therapeutic interventions, such as dual diagnosis treatment, are typically needed to address these chronic conditions effectively.

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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 ["A","B","D","E"]

Explanation

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