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. 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. Buprenorphine B. Diazepam C. Varenicline D. Rimonabant

Correct Answer is B

Explanation

A. Buprenorphine is primarily used for the treatment of opioid dependence, not alcohol detoxification. It is a partial opioid agonist and can precipitate withdrawal symptoms in individuals dependent on opioids. Therefore, it is not appropriate for alcohol detoxification and would not typically be administered in this context.
B. Diazepam belongs to the benzodiazepine class of medications and is commonly used during alcohol detoxification. Benzodiazepines help manage symptoms of alcohol withdrawal, including anxiety, tremors, agitation, and seizures. They work by enhancing the effects of gamma-aminobutyric acid (GABA), which is an inhibitory neurotransmitter in the brain. Diazepam has a longer duration of action and is preferred in managing alcohol withdrawal due to its smoother pharmacokinetic profile compared to shorter-acting benzodiazepines.
C. Varenicline is a medication used for smoking cessation. It works by partially activating nicotine receptors in the brain, reducing the pleasurable effects of smoking and decreasing withdrawal symptoms. It is not indicated for alcohol detoxification and would not be used in this context.
D. Rimonabant is a cannabinoid receptor antagonist that was once used for weight loss but has been withdrawn from the market due to psychiatric side effects, including depression and anxiety. It is not indicated for alcohol detoxification and would not be administered in this context.

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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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Explanation

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