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. Lithium can affect sodium and potassium balance in the body, but it does not specifically require a decrease in dietary potassium. Instead, sodium intake should be kept consistent because lithium excretion is influenced by sodium levels. Therefore, decreasing dietary potassium is not a recommended intervention.
B. Lithium can sometimes cause weight gain as a side effect. Increasing daily caloric intake is not a standard intervention when starting lithium. Clients should be encouraged to maintain a balanced diet and regular exercise regimen to manage potential weight changes.

C. Hypoglycemia is not a common side effect of lithium. Therefore, monitoring for hypoglycemia is not necessary when a client is taking lithium.
D. Administering lithium with meals can help reduce gastrointestinal side effects, such as nausea and upset stomach, which are common when starting the medication. It also helps with consistent absorption and reduces the peak serum concentration of lithium, which can minimize side effects and stabilize blood levels.

A. "The PSDA becomes applicable when a client reaches 65 years of age." B. "A witness is legally required to sign a client's living will." C. "Advance directives do not apply to clients receiving mental health care." D. "A client can verbally designate a durable power of attorney."

Correct Answer is D

Explanation

A. The PSDA applies to all adult clients regardless of age. It ensures that adults have the right to make decisions about their medical care, including the right to accept or refuse treatment, regardless of whether they are elderly or not. Age is not a factor in the applicability of the PSDA.
B. While it's common for a living will to be witnessed, it is not a legal requirement under the PSDA.
C. Advance directives are applicable to all clients, including those receiving mental health care.
D. The Patient Self-Determination Act (PSDA) ensures that adult patients are informed about their rights to make decisions regarding their medical care, including the right to accept or refuse treatment and to prepare an advance directive.

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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 contributing to the plan of care for a client who has a new prescription for lithium. Which of the following interventions should the nurse recommend?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about the Patient Self-Determination Act (PSDA). Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is D

Explanation

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