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","B","C","D","E","F","G"]

Explanation

The findings that require immediate follow-up are: Client confused and agitated: This could indicate a neurological issue or other serious condition that needs immediate attention.
Appearance is disheveled: This could suggest neglect or other issues that need to be addressed.
Mucous membranes dry: This could indicate dehydration which can be serious if not addressed promptly. Client states “Can you ask that person to leave my room?” Client is pointing to an empty chair: This could indicate hallucinations or other mental health concerns that need immediate attention.
Temperature 38.6°C (101.5°F): This is a fever and could indicate an infection or other medical condition that needs immediate attention.
Blood pressure 158/96 mm Hg: This is high and could indicate hypertension or other cardiovascular issues that need immediate attention.

A. "The PSDA becomes applicable when a client reaches 65 years of age.”. B. "Bulimia nervosa is difficult to notice because a person might be of average or ideal body weight.”. C. "As long as a person is not vomiting after eating, they do not have bulimia nervosa.”. D. "People who have bulimia nervosa are at risk for developing diabetes mellitus.”.

Correct Answer is B

Explanation

Choice A rationale:

This statement is incorrect. People with bulimia nervosa often consume large amounts of food in a short period of time, known as binge eating.

Choice B rationale:

This statement is correct. Despite the binge-purge cycle, individuals with bulimia nervosa can maintain an average or ideal body weight, making the disorder less noticeable.

Choice C rationale:

This statement is incorrect. While self-induced vomiting is a common method of purging in bulimia nervosa, other methods such as excessive exercise, fasting, or misuse of laxatives, diuretics, or enemas can also be used.

Choice D rationale:

This statement is incorrect. While bulimia nervosa can lead to various health complications, it is not directly associated with the development of diabetes mellitus.

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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

Correct Answer is ["A","B","C","D","E","F","G"]

Explanation

A nurse is participating in a community program about eating disorders. Which of the following information about bulimia nervosa should the nurse include in the presentation?.

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?.