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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Administering an antianxiety medication can help manage symptoms, but it’s not the first action a nurse should take.
Choice B rationale:
Calculating the client’s score on the Hamilton Rating Scale for Anxiety is the first step in assessing the severity of the client’s anxiety.
Choice C rationale:
Explaining the use of response prevention can be beneficial, but it’s not the first action the nurse should take.
Choice D rationale:
Discussing the benefits of relaxation exercises can help manage anxiety, but it’s not the first action the nurse should take.
Correct Answer is A
Explanation
Choice A rationale:
Acknowledging an inability to control drinking is the first step in many recovery models, including the 12-step program of Alcoholics Anonymous. This step involves admitting that alcohol has taken over one’s life.
Choice B rationale:
Agreeing to a prescription for an alcohol use deterrent can be a part of the recovery process, but it is not typically the first step.
Choice C rationale:
Incorporating a form of spirituality into daily life can be a part of the recovery process for some individuals, but it is not typically the first step.
Choice D rationale:
Forming a close support network is crucial in the recovery process, but it comes after acknowledging the problem.
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