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 D

No explanation

A. "Having a newborn must be stressful. Do you have other children?". B. "Tell me about your baby. Where is she now?". C. "Do you have a friend who could help you?". D. "Have you discussed this with your partner?".

Correct Answer is B

Explanation

Choice A rationale:

While it’s important to understand the client’s situation, the immediate safety of the baby is the priority.

Choice B rationale:

This response is the priority as it assesses the immediate safety of the baby.

Choice C rationale:

While support is important, the immediate safety of the baby is the priority.

Choice D rationale:

While communication with the partner is important, the immediate safety of the baby is the priority.

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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 reinforcing teaching with a newly licensed nurse about the Patient Self-Determination Act (PSDA). Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?.

Correct Answer is D

A client who delivered a healthy newborn 4 weeks ago calls her provider's office and tells the nurse, "This baby constantly cries. My partner works all the time, and I can't take any more.”. Which of the following responses is the nurse's priority?.

Correct Answer is B

Explanation

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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?.