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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?.

A.

Timeout

B.

Restraint.

C.

Diversion.

D.

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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Related Questions

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.

Correct Answer is ["A","B","C","D","E","F"]

Explanation

The findings that require immediate follow-up are:

  • Client confused and agitated: This could indicate a neurological issue or other serious condition that needs immediate attention.
  • Appearance is disheveled: This could suggest neglect or other issues that need to be addressed.
  • Mucous membranes dry: This could indicate dehydration which can be serious if not addressed promptly.
  • Client states “Can you ask that person to leave my room?” Client is pointing to an empty chair: This could indicate hallucinations or other mental health concerns that need immediate attention.
  • Temperature 38.6°C (101.5°F): This is a fever and could indicate an infection or other medical condition that needs immediate attention.
  • Blood pressure 158/96 mm Hg: This is high and could indicate hypertension or other cardiovascular issues that need immediate attention.

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