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:

A motor-vehicle crash is an adventitious crisis, not a maturational one.

Choice B rationale:

A child leaving for college is a normal developmental milestone that can cause stress.

Choice C rationale:

Loss of a job is a situational crisis, not a maturational one.

Choice D rationale:

Divorce is a situational crisis, not a maturational one.

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?.

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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?.