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.
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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Related Questions
Correct Answer is B
Explanation
Choice A reason: Providing a client with a timeline for grieving is not recommended as grief is a highly individual experience and does not follow a set timeline. Each person's journey through grief is unique, and imposing a timeline may invalidate their feelings and hinder the natural process of grieving.
Choice B reason: Encouraging the client to express their feelings is considered a best practice in nursing care for patients with dementia experiencing anticipatory grief. It allows the patient to acknowledge and work through their emotions, which is an important aspect of coping with grief. Open communication can also help the nurse to assess the patient's emotional state and provide appropriate support.
Choice C reason: While showing sympathy can be comforting, it is more beneficial to show empathy. Empathy involves understanding and sharing the feelings of another, which helps in building a stronger connection and providing more personalized care. Sympathy might sometimes be perceived as pity, which can be counterproductive in the therapeutic relationship.
Choice D reason: Sharing personal stories of grief with the client is generally not advised as the focus should remain on the client's experiences. The nurse's role is to facilitate the client's expression of grief, not to shift the focus to their own experiences. Personal stories may also trigger additional stress for the client.
Correct Answer is D
Explanation
Choice A reason: Witnessing an informed consent is a legal process that typically requires a licensed nurse or healthcare provider to ensure that the client fully understands the procedure and its risks. It is not appropriate to delegate this task to assistive personnel.
Choice B reason: Explaining the benefits of light therapy involves providing health education, which should be done by a licensed nurse or healthcare provider who has the necessary knowledge and training to ensure accurate information is conveyed.
Choice C reason: Discussing the adverse effects of medications is part of medication education and should be conducted by a licensed nurse or healthcare provider. Assistive personnel are not trained to provide this level of detailed medical information.
Choice D reason: Participating in solitary activities does not require clinical judgment and can be safely delegated to assistive personnel. This task involves engaging the client in activities that can help manage their mania and provide a therapeutic environment.
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