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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Encouraging the client to attend a daily exercise program on the unit is beneficial for the client’s health, but it does not demonstrate the ethical principle of veracity, which involves truthfulness and honesty.
Choice B rationale:
Maintaining the client’s confidentiality about a substance use disorder is an important aspect of nursing care, but it demonstrates the ethical principle of confidentiality, not veracity.
Choice C rationale:
Reinforcing information on the potential adverse effects of a medication with the client is an example of veracity. The nurse is being truthful and transparent about the potential risks associated with the medication.
Choice D rationale:
Respecting the client’s right to refuse to attend a group therapy session demonstrates the ethical principle of autonomy, not veracity.
Correct Answer is B
Explanation
Choice A rationale:
This statement is incorrect. Opioid withdrawal typically results in tachycardia, not bradycardia.
Choice B rationale:
This statement is correct. Diarrhea is a common symptom of opioid withdrawal.
Choice C rationale:
This statement is incorrect. Opioid withdrawal often results in restlessness and agitation, not hypokinesis.
Choice D rationale:
This statement is incorrect. Opioid withdrawal typically results in dilated pupils, not meiosis.
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