Difficulty: Medium
Average Score: 79%
Simulated
A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply.)
Correct answer
A,B
Rationale
Correct Answer: A, B
Rationale:
A: Identifying the client's stressors is important to understand the underlying cause of the behavior and helps in addressing the root issue.
B: Talking to the client using short, simple sentences can help in de-escalating the situation and ensuring effective communication.
C: Speaking to the client in a loud voice may escalate the situation further by increasing agitation and aggression.
D: Requesting security guards to restrain the client should be a last resort and may lead to physical harm and trauma.
E: Standing directly in front of the client can be perceived as confrontational and may escalate the situation further.
Rationale:
A: Identifying the client's stressors is important to understand the underlying cause of the behavior and helps in addressing the root issue.
B: Talking to the client using short, simple sentences can help in de-escalating the situation and ensuring effective communication.
C: Speaking to the client in a loud voice may escalate the situation further by increasing agitation and aggression.
D: Requesting security guards to restrain the client should be a last resort and may lead to physical harm and trauma.
E: Standing directly in front of the client can be perceived as confrontational and may escalate the situation further.