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. 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. Absence of seizures B. Reduction in hand tremors C. Improved mood D. Decreased hallucinations

Correct Answer is C

Explanation

A. Fluoxetine is not indicated for the treatment of seizures. Its primary therapeutic effect is related to mood stabilization through serotonin reuptake inhibition in the brain. Therefore, absence of seizures would not be an expected outcome of fluoxetine therapy.
B. Hand tremors are not typically a direct symptom of depression or anxiety but can occur as a side effect of certain medications or due to anxiety-related physiological responses. Fluoxetine itself does not typically cause or treat hand tremors directly. Therefore, while tremor reduction might occur as a result of improved mood and reduced anxiety, it is not a direct therapeutic outcome of fluoxetine.
C. Improved mood is one of the primary expected outcomes of fluoxetine therapy. SSRIs like fluoxetine work by increasing serotonin levels in the brain, which helps regulate mood and alleviate symptoms of depression and anxiety. Clients typically experience a reduction in feelings of sadness, hopelessness, and anxiety, leading to an overall improvement in mood.
D. Hallucinations are not a typical symptom of depression or anxiety disorders but can occur in conditions such as schizophrenia or psychotic depression. Fluoxetine is not primarily indicated for treating hallucinations.

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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

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who reports drinking alcoholic beverages daily but has not consumed alcohol in the last 24 hr. Which of the following findings should the nurse identify as a manifestation of alcohol withdrawal?

Correct Answer is D

Explanation

A nurse is contributing to the plan of care for a client who is to start therapy with fluoxetine. Which of the following is an expected outcome for this client?

Correct Answer is C

Explanation

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