A nurse is caring for a client who becomes extremely agitated and asks if they can go to a separate room to be alone for an hour. The nurse should document which of the following de- escalation techniques in the client's medical record?

Timeout

Restraint

Diversion

Therapeutic hold

Answer and Explanation

The Correct Answer is A

A.   This technique involves allowing the client to remove themselves from the situation causing agitation temporarily. It is a de-escalation technique where the client can regain composure and reduce agitation by being alone or in a quieter environment. The nurse ensures the environment is safe and monitors the client during this time.
B.   Restraint involves physically restricting the client's movement to prevent harm to themselves or others when they are in a state of extreme agitation and are at risk of causing harm. It is used as a last resort and typically requires a healthcare provider's order due to the potential risks and ethical considerations.
C.   Diversion involves redirecting the client's attention away from the source of agitation to something else, such as a calming activity or a change of topic. It can help shift the client's focus and reduce escalating emotions.
D.   Also known as a therapeutic restraint hold, this technique is used to safely manage a client who is agitated and may become physically aggressive. It involves trained staff using specific holds to restrain the client in a way that prevents harm while allowing for therapeutic communication.

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Correct Answer is D

Explanation

A. While medications like SSRIs (Selective Serotonin Reuptake Inhibitors) or benzodiazepines may eventually be part of the treatment plan for OCD, administering medication should not be the first action unless the client is in acute distress or experiencing severe anxiety symptoms that require immediate pharmacological intervention.
B. This option involves assessing the severity of anxiety symptoms, which is important for understanding the client's baseline anxiety level. However, calculating this score is not the first action. It can be done later as part of the comprehensive assessment to guide ongoing treatment planning.
C. Relaxation exercises, such as deep breathing or progressive muscle relaxation, can help manage anxiety symptoms in clients with OCD. However, before initiating specific interventions like relaxation exercises, the nurse should first establish rapport, assess the client's current level of distress, and gather information about the client's symptoms and coping mechanisms.
D. Response prevention is a cognitive-behavioral therapy technique used in the treatment of OCD, where clients are prevented from engaging in compulsive behaviors. This should follow after thorough assessment of the actual psychological state of the client.

A. Acknowledge an inability to control drinking. B. Agree to a prescription for an alcohol use deterrent. C. Form a close support network. D. Incorporate a form of spirituality into daily life.

Correct Answer is A

Explanation

A. This is a crucial first step in recovery. It involves recognizing and accepting that one has lost control over their drinking and that alcohol use is causing negative consequences in their life. Without acknowledging this lack of control, individuals may not be motivated to seek or engage in treatment.
B. While medications such as disulfiram (Antabuse) or naltrexone (Revia) can be part of a comprehensive treatment plan for alcohol use disorder, agreeing to a prescription for an alcohol use deterrent is not typically the first step in recovery. It usually follows assessment, acknowledgment of the problem, and development of a treatment plan in collaboration with healthcare providers.
C. Building a strong support network is indeed crucial for long-term recovery. This network may include family, friends, peers in recovery, and support groups like Alcoholics Anonymous (AA). However, forming this support network is often a step that occurs as part of ongoing treatment and recovery efforts rather than the very first step.

D. Incorporate a form of spirituality into daily life: Spirituality or a sense of purpose can be a significant component of recovery for some individuals, providing strength and motivation. However, it is not universally considered the first step in recovery. Spirituality may be explored and integrated into the recovery journey as individuals progress in treatment and self-discovery.

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A nurse is caring for a client who becomes extremely agitated and asks if they can go to a separate room to be alone for an hour. The nurse should document which of the following de- escalation techniques in the client's medical record?

Nursing Test Bank

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A nurse is caring for a newly admitted client who has obsessive-compulsive disorder. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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