A nurse in a mental health facility is caring for a client who becomes upset and breaks a chair when a visitor does not arrive. The client remains agitated following initial verbal attempts to calm him down. Which of the following interventions should the nurse implement first?
Plan with the client for how he can better handle frustration.
Place the client in a monitored seclusion room until he is calm.
Offer the client an antianxiety medication.
Restrain the client to prevent injury to himself or others.
The Correct Answer is C
A. Planning with the client for how he can better handle frustration (option A) is a valuable intervention, but it may not be immediately effective in the midst of heightened agitation. It is better suited for a calmer, more reflective time.
B. Placing the client in a monitored seclusion room until he is calm (option B) is an option for managing extreme agitation, but it should be used cautiously and as a last resort. Offering medication and attempting verbal de-escalation are generally preferable initial steps.
C. Offer the client an antianxiety medication.
When dealing with a client who is agitated and potentially escalating to a more volatile state, offering an antianxiety medication can be a helpful and immediate intervention to manage acute distress. It can aid in calming the client down and create an environment where other therapeutic interventions can be more effectively implemented.
D. Restraining the client to prevent injury to himself or others (option D) is a highly invasive intervention and should only be considered when there is an imminent risk of harm to the client or others. It is generally not the first choice in managing agitation due to its potential negative impact on the therapeutic relationship and the client's well-being.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Constantly talking about the traumatic experience is a symptom of intrusive thoughts and re-experiencing, which is characteristic of PTSD.
B. The client is easily startled by loud voices.
Individuals with PTSD often experience heightened arousal and increased reactivity to stimuli. Being easily startled by loud voices is a common symptom of hypervigilance and increased arousal seen in PTSD.
C. Reporting satisfying personal relationships with family and close friends is less likely in individuals with PTSD. PTSD can negatively impact interpersonal relationships due to symptoms such as emotional numbing, avoidance, and hypervigilance.
D. Constant drowsiness and sleeping 11-12 hours daily are not typical findings in PTSD. Individuals with PTSD may experience sleep disturbances, such as insomnia, nightmares, or hyperarousal-related sleep problems.
Correct Answer is ["A","B","D","E"]
Explanation
A. Exhibiting clang associations: Correct. Clang associations involve the repetition of words or phrases based on sound rather than meaning and are often seen in manic states.
B. Interacting with others in a flirtatious way: Correct. Manic individuals may exhibit increased social and sexual behaviors, including being flirtatious.
C. Reports sleeping for long periods of time: Incorrect. Manic episodes are typically associated with decreased need for sleep rather than increased. Reports of sleeping for long periods would be more indicative of a depressive episode in bipolar disorder.
D. Talking in rapid continuous speech: Correct. Rapid and continuous speech is a common characteristic of manic episodes in bipolar disorder.
E. Reports spending large sums of money: Correct. Excessive spending is a common manifestation of manic behavior, often without consideration of the consequences.
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