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:

Making a personal introduction to the client at each interaction is a recommended approach for clients with dementia. It helps to orient the client and establish a connection, which can reduce confusion and anxiety.

Choice B rationale:

Giving a client with dementia a list of foods to choose from for dinner may be overwhelming due to impaired decision-making abilities.

Choice C rationale:

Choice D rationale:

Providing a dark environment for sleeping can be disorienting for a client with dementia. A low level of light can help the client maintain orientation to their surroundings.

A. Discussing childhood memories during group therapy B. Playing board games with other clients to enhance cognition. C. Making a unit calendar to promote orientation. D. Encouraging thought-stopping to block undesirable thoughts.

Correct Answer is A

Explanation

Choice A rationale:

Discussing childhood memories during group therapy is a key component of reminiscence therapy. It helps older adults recall past experiences and can improve their mood and cognitive function.

Choice B rationale:

Playing board games can enhance cognition, but it’s not specific to reminiscence therapy.

Choice C rationale:

Making a unit calendar promotes orientation, but it’s not part of reminiscence therapy.

Choice D rationale:

Encouraging thought-stopping can help block undesirable thoughts, but it’s not a strategy used in reminiscence therapy.

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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?.