A nurse is caring for a client who becomes extremely agitated and asks if they can go to a separate room to be alone for an hour.
The nurse should document which of the following de-escalation techniques in the client's medical record?.

Timeout

Restraint.

Diversion.

Therapeutic hold.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

A timeout is a de-escalation technique where the client is allowed to spend time alone in a safe environment to regain control.

Choice B rationale:

Restraint is not a de-escalation technique. It is a last resort measure used when other methods have failed and the client is a danger to themselves or others.

Choice C rationale:

Diversion is a technique used to distract the client from a stressful situation, not a de-escalation technique.

Choice D rationale:

A therapeutic hold is a type of physical restraint, not a de-escalation technique.

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Correct Answer is B

Explanation

Choice A rationale:

This statement is incorrect. People with bulimia nervosa often consume large amounts of food in a short period of time, known as binge eating.

Choice B rationale:

This statement is correct. Despite the binge-purge cycle, individuals with bulimia nervosa can maintain an average or ideal body weight, making the disorder less noticeable.

Choice C rationale:

This statement is incorrect. While self-induced vomiting is a common method of purging in bulimia nervosa, other methods such as excessive exercise, fasting, or misuse of laxatives, diuretics, or enemas can also be used.

Choice D rationale:

This statement is incorrect. While bulimia nervosa can lead to various health complications, it is not directly associated with the development of diabetes mellitus.

A. Discourage visitation from the client's family B. Provide a high-stimulation environment for the client. C. Limit the client's need to make decisions. D. Keep the client's room dark at night.

Correct Answer is C

Explanation

Choice A rationale:

Discouraging visitation from the client’s family could increase feelings of isolation and confusion, which could exacerbate delirium.

Choice B rationale:

A high-stimulation environment could overstimulate the client and worsen delirium.

Choice C rationale:

Limiting the client’s need to make decisions can reduce stress and confusion, which can help manage delirium.

Choice D rationale:

Keeping the client’s room dark at night could disrupt the client’s sleep-wake cycle and potentially worsen delirium.

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A nurse is caring for a client who becomes extremely agitated and asks if they can go to a separate room to be alone for an hour. The nurse should document which of the following de-escalation techniques in the client's medical record?.

Nursing Test Bank

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A nurse is caring for a client who becomes extremely agitated and asks if they can go to a separate room to be alone for an hour.
The nurse should document which of the following de-escalation techniques in the client's medical record?.