A nurse takes a dinner tray to a patient who has been pacing and preoccupied. The patient suddenly places his butter knife against his throat and demands that everyone stay back
Which of the following considerations should be kept in mind in responding to this situation? Select all that apply. a. Maintaining and conveying a sense of calm confidence helps calm the patient.
b. The patient will require restraint because he has presented a danger to self.
c. In that the patient is not in control, the nurse should control what happens.
d. Determine what the patient considers to be his need, to be important to him.
e. Ask the patient for ideas about what he thinks would help resolve the crisis.
f. Tell the patient that your goal is that everyone remains safe while you talk.
A, D, E, F
To de-escalate a situation such as this, a number of principles should be kept in mind. One is that staff should act as they intend for the patient to act, that is, they should remain calm and convey a sense of confidence that the situation will be resolved safely. Involving the patient in identifying the triggers or stressors underlying the crisis and in identifying possible solutions is much more likely to lead to a positive resolution. The alternative, wherein staff act on their assumptions about the causes of the event are and determine solutions unilaterally, is less likely to be effective and may even provoke the patient to escalate further if the precipitating event entailed the patient feeling he did not have control over what was happening to him. Stating staff's goal of safety for all is also important and should be added to the patient's goals; defining the safety of all as the priority also conveys that staff care about the patient. Although some staff feel that highly restrictive measures are required any time a person has endangered himself or others, in point of fact this decision should be made on a case-by-case basis. The prospect of seclusion or restraint can prolong and intensify a crisis and/or lead to further crises.
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The nurse is providing teaching to a client diagnosed with a social phobia. Which client statement indicates appropriate understanding of the information presented?
A) "I try to avoid all situations where I am expected to talk in front of other people." B) "I can control anxiety by deep breathing and relaxing before talking in front of other people." C) "I take an antianxiety pill before I have to do anything in front of other people." D) "I can have a drink before I speak in front of other people."
A client reports confusion about having an alcoholic drink prior to retiring for the evening. What information can the nurse provide to the client to promote understanding?
A) Alcohol can increase the time needed to fall asleep. B) Alcohol is disruptive of the second half of the sleep cycle. C) Alcohol can enable an individual to sleep through the entire night. D) Alcohol has an initially depressant effect.
Which of the following are considered internal female genitalia? Select all that apply
A) mons pubis B) labia majora C) ovaries D) uterus E) fallopian tubes F) clitoris
A client in labor is a Lebanese immigrant, and she explains that in the Muslim faith, the baby's name is selected after delivery, as it is God's will whether or not the baby will be born. Which nursing response is appropriate?
1. "Are you afraid your baby will not live?" 2. "We have a very low rate of complications at this facility." 3. "In the United States, you can feel free to choose your baby's name prior to the delivery." 4. "Thank you for explaining that to me. By sharing your cultural beliefs with me, you are helping me to provide you with the best possible care."