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 B

Explanation

Choice A rationale:

Documenting the client’s behavior every hour is not necessary. The nurse should monitor and document the client’s condition, but this does not need to be done every hour.

Choice B rationale:

Providing range-of-motion exercises to all extremities every 2 hours is important when a client is in restraints. This helps to prevent muscle stiffness and maintain circulation.

Choice C rationale:

The provider does not need to renew the prescription every 24 hours. The use of restraints should be reassessed regularly, but a new prescription is not required unless the restraints are removed and then need to be reapplied.

Choice D rationale:

Keeping staff interactions with the client to a minimum is not recommended. The client should be monitored closely and regular interaction can help to calm the client and reduce the need for restraints.

A. Psychodrama B. Crisis intervention. C. Dual diagnosis treatment. D. Codependency support.

Correct Answer is C

Explanation

Choice A rationale:

Psychodrama is a therapeutic approach that uses dramatic role play to help clients gain insight into their feelings and behaviors. However, it may not be the most effective for a client with antisocial personality disorder and alcohol dependency.

Choice B rationale:

Crisis intervention is a short-term therapy to stabilize a client during an acute crisis. It may not address the long-term needs of a client with antisocial personality disorder and alcohol dependency.

Choice C rationale:

Dual diagnosis treatment is designed for clients who have a mental health disorder and a substance use disorder. This would be the most appropriate for a client with antisocial personality disorder and alcohol dependency.

Choice D rationale:

Codependency support groups are typically for family members and friends of individuals with substance use disorders. They may not be the most beneficial for the client themselves.

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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?.

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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?.