A client is becoming increasingly agitated, anxious, and tense.
The nurse notes a clenched jaw and a change in the pitch of the client's voice.
Which of the following interventions should the nurse implement first?.

Obtain a prescription for haloperidol.

Take the client to the seclusion room.

Verbally de-escalate the client.

Place the client in restraints.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Obtaining a prescription for haloperidol is not the first intervention the nurse should implement. Medication should be considered only after non-pharmacological interventions have been attempted.

Choice B rationale:

Taking the client to the seclusion room is not the first intervention the nurse should implement. Seclusion should be used only as a last resort when all other interventions have failed and the client is a danger to themselves or others.

Choice C rationale:

Verbally de-escalating the client is the first intervention the nurse should implement. This involves using calm, clear communication to help the client regain control of their emotions.

Choice D rationale:

Placing the client in restraints is not the first intervention the nurse should implement. Restraints should be used only as a last resort when all other interventions have failed and the client is a danger to themselves or others.

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Correct Answer is A

Explanation

Choice A rationale:

Acknowledging an inability to control drinking is the first step in many recovery models, including the 12-step program of Alcoholics Anonymous. This step involves admitting that alcohol has taken over one’s life.

Choice B rationale:

Agreeing to a prescription for an alcohol use deterrent can be a part of the recovery process, but it is not typically the first step.

Choice C rationale:

Incorporating a form of spirituality into daily life can be a part of the recovery process for some individuals, but it is not typically the first step.

Choice D rationale:

Forming a close support network is crucial in the recovery process, but it comes after acknowledging the problem.

A. Encouraging the client to attend a daily exercise program on the unit. B. Maintaining the client's confidentiality about a substance use disorder. C. Reinforcing information on the potential adverse effects of a medication with the client. D. Respecting the client's right to refuse to attend a group therapy session.

Correct Answer is C

Explanation

Choice A rationale:

Encouraging the client to attend a daily exercise program on the unit is beneficial for the client’s health, but it does not demonstrate the ethical principle of veracity, which involves truthfulness and honesty.

Choice B rationale:

Maintaining the client’s confidentiality about a substance use disorder is an important aspect of nursing care, but it demonstrates the ethical principle of confidentiality, not veracity.

Choice C rationale:

Reinforcing information on the potential adverse effects of a medication with the client is an example of veracity. The nurse is being truthful and transparent about the potential risks associated with the medication.

Choice D rationale:

Respecting the client’s right to refuse to attend a group therapy session demonstrates the ethical principle of autonomy, not veracity.

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A client is becoming increasingly agitated, anxious, and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a substance use disorder clinic is explaining the alcohol recovery process to a client's family. Which of the following should the nurse identify as the first step toward successful recovery from alcohol use disorder?.

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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A client is becoming increasingly agitated, anxious, and tense.
The nurse notes a clenched jaw and a change in the pitch of the client's voice.
Which of the following interventions should the nurse implement first?.