After a nurse addresses an agitated client by setting limits in a calm, direct manner, the client begins pacing, exhibiting a clenched jaw and fists. The nurse would evaluate the approach as ineffective because:
1. The nurse lacks rapport with the client.
2. The nurse lacks adequate de-escalation and limit setting skills.
3. Some clients have limited control, so verbal interventions may not work, but this is not reflective of the nurse's skill.
4. In some cases verbal de-escalation and limit setting will not work and the nurse should start with a more restrictive measure.
3
Rationale: Not all clients will respond to verbal interventions, but this does not mean the nurse lacks skill. The nurse should always follow the principle of least restrictive measures first, even if it does not appear that it may work. A nurse's verbal skills or ability to establish rapport are not necessarily measured by the client's response, as some clients are more out of control than others.
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