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:

Re-engaging the child in an appropriate activity is a good example of the redirection technique.

Choice B rationale:

Moving closer to the child when they are agitated could escalate the situation rather than calm it.

Choice C rationale:

Using role-playing to enhance new behavioral skills is a good strategy, but it is not an example of the redirection technique.

Choice D rationale:

Ignoring attention-seeking behaviors could lead to an escalation of those behaviors as the child seeks attention.

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

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Correct Answer is A

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Correct Answer is B

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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?.