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 A

Explanation

Choice A rationale:

Cardiac arrhythmia is a contraindication for electroconvulsive therapy (ECT) because ECT can cause changes in heart rate and blood pressure, which could be dangerous for someone with an existing heart condition.

Choice B rationale:

Crohn’s disease is not a contraindication for ECT. It is a chronic inflammatory bowel disease, and while it can cause significant health problems, it does not directly affect the safety or efficacy of ECT.

Choice C rationale:

Renal colic, a type of pain that can occur when a kidney stone is present, is not a contraindication for ECT. It is unrelated to the brain and nervous system and does not affect the safety or efficacy of ECT.

Choice D rationale:

Asthma is not a contraindication for ECT. While severe asthma should be well-controlled before any procedure that involves anesthesia, it is not a direct contraindication for ECT.

A. Encourage the client to visit with the sibling. B. Tell the sibling the client does not want visitors. C. Arrange for the sibling to visit the client in the dayroom. D. Refer the sibling to the client's provider.

Correct Answer is B

Explanation

Choice A rationale:

It’s not appropriate to pressure the client into seeing visitors.

Choice B rationale:

It’s important to respect the client’s wishes and communicate them to the sibling.

Choice C rationale:

This could potentially cause distress for the client.

Choice D rationale:

While it might be helpful to involve the provider, the immediate issue can be addressed by the nurse.

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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

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who is to receive electroconvulsive therapy. The nurse should notify the provider for which of the following findings?.

Correct Answer is A

Explanation

A nurse is speaking with the sibling of a client who refuses to see visitors. Which of the following actions should the nurse take?.

Correct Answer is B

Explanation

A nurse is caring for a client who is experiencing a situational crisis. Which of the following actions should the nurse take first?.

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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?.