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 C

Explanation

Choice A rationale:

Absence of impulsive behaviors is not a risk factor for becoming a perpetrator of child abuse. Impulsive behaviors can lead to unpredictable and potentially harmful actions, but their absence does not increase the risk of abusive behavior.

Choice B rationale:

Being involved in community activities is generally a positive factor and does not increase the risk of becoming a perpetrator of child abuse. It can provide a support network and positive role models, which can help prevent abusive behaviors.

Choice C rationale:

Low tolerance for frustration is a risk factor for becoming a perpetrator of child abuse. Frustration can lead to anger and potentially harmful actions, especially if the person does not have effective coping mechanisms.

Choice D rationale:

A submissive personality is not a risk factor for becoming a perpetrator of child abuse. While it may affect interpersonal relationships, it does not directly increase the risk of abusive behavior.

A. Use light restraints while the client is in bed. B. Place a lock at the top of doors leading outside. C. Encourage the client to nap during the day. D. Administer an antianxiety medication before bedtime.

Correct Answer is B

Explanation

Choice A rationale:

Using restraints can lead to injury and is generally a last resort.

Choice B rationale:

Placing a lock at the top of doors can prevent the client from wandering outside and getting lost or injured.

Choice C rationale:

Encouraging napping during the day can actually disrupt the client’s sleep cycle and increase nighttime wakefulness.

Choice D rationale:

While medication can be helpful, non-pharmacological interventions should be tried 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?.

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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?.