A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply.)

Identify the client's stressors.

Talk to the client using short, simple sentences.

Speak to the client in a loud voice.

Request that security guards restrain the client.

Stand directly in front of the client.

Answer and Explanation

Correct Answer : A,B

Choice A reason: Identifying the client's stressors is a crucial step in managing agitation. Understanding what triggers the client's distress can help the nurse to address the underlying issues and de-escalate the situation.

Choice B reason: Using short, simple sentences can help to communicate effectively with an agitated client. It ensures that the client can process the information without being overwhelmed, which is important for calming the situation.

Choice C reason: Speaking to the client in a loud voice is not recommended as it may escalate the situation. It's important to maintain a calm and soothing tone to avoid further agitation.

Choice D reason: Requesting that security guards restrain the client should be a last resort, only if the client poses an immediate threat to themselves or others. Less restrictive measures should be attempted first.

Choice E reason: Standing directly in front of an agitated client can be perceived as confrontational. It's better to maintain a non-threatening stance and ensure there is enough space to allow the client to feel safe.

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Correct Answer is A

Explanation

Choice A reason: Guided imagery is a relaxation technique that can help calm the mind and is beneficial for individuals with anxiety disorders. It involves envisioning a peaceful scene or series of experiences that can distract from anxious thoughts. This method can be particularly helpful before bedtime to ease the transition into sleep.

Choice B reason: Lying in bed and trying to force oneself to fall asleep can actually lead to increased frustration and anxiety, making it harder to fall asleep. It's recommended to leave the bed if unable to sleep and engage in a quiet activity until feeling sleepy.

Choice C reason: Eating a substantial meal before bed can lead to discomfort and disrupt sleep. It's better to have a light snack if needed and avoid heavy meals close to bedtime.

Choice D reason: Restricting sleep can exacerbate anxiety and is not recommended. It's important to maintain a regular sleep schedule and ensure adequate sleep to manage anxiety symptoms effectively.

A. Tell the client that their experience is not real. B. Avoid asking direct questions about the client's experience. C. Focus the client on reality-based activities. D. Convey sympathy for the client's experience.

Correct Answer is C

Explanation

Choice A reason: Telling a client that their experience is not real can be invalidating and may damage the therapeutic relationship between the nurse and the client. It is essential to acknowledge the client's experience as real to them and provide support without reinforcing the hallucination.

Choice B reason: While it is important not to reinforce hallucinations, avoiding direct questions about the client's experience can hinder the nurse's ability to assess the client's condition fully. It is better to ask open-ended questions that allow the client to describe their experience without feeling judged.

Choice C reason: Focusing the client on reality-based activities can help distract them from the hallucinations and ground them in the present moment. Activities such as listening to music, engaging in conversation, or participating in a physical activity can help reduce the intensity of hallucinations and provide a sense of control.

Choice D reason: Conveying sympathy for the client's experience is compassionate and can help build trust. However, it is crucial to balance empathy with encouragement to engage in reality-based activities and strategies to manage the hallucinations effectively.

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A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply.)

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