The principle on which nursing intervention should be predicated when a client's aggression quickly
escalates is
a. staff should match client's affective level, tone of voice, and so forth.
b. immediately use physical containment measures.
c. ask the client what will be most helpful to him or her.
d. begin with the least restrictive measure possible.
D
Legal constraints require that staff use the least restrictive measure possible. This becomes the
guiding principle for intervention. Option A would result in greater escalation. Option B: Physical
containment is seldom the least restrictive measure. Option C: Asking the out-of-control client what
to do is rarely helpful. It may be an effective strategy during the preaggressive phase but is less
effective during escalation.
You might also like to view...
An older patient complains of dry skin and asks for advice. Which advice should the nurse offer for improving dry skin?
a. Add oil to the bath water to keep skin soft. b. Use tepid bath water. c. Move to a climate with lower humidity. d. Vigorously dry skin with a rough towel after bathing.
A hospital's disaster management team is reviewing the disaster plan after reading about a hospital that was destroyed by a tornado's direct hit
What questions should team members ask themselves? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Standard Text: Select all that apply. 1. "What are our current capabilities for evacuation?" 2. "Do we have sufficient resources in any other areas to continue operations if this happens to us?" 3. "Are there physical training needs that we have not filled?" 4. "What education should we provide to the staff and community?" 5. "Would we eventually rebuild if the hospital was destroyed?"
A wife of a man with long-term alcoholism wants to help her husband quit drinking. The nurse tells her that an initial approach might be for a group of friends and family to confront the patient with his alcoholism
What should this group be prepared to indicate during this confrontation? a. He needs help; his drinking is out of hand. b. They are fed up with him and will no longer be his friend. c. They reject his drinking but think he is a valuable person. d. He is still their friend even if he does not stop drinking.
A nurse is teaching unlicensed assistive personnel (UAP) how to take accurate blood pressure on children
The nurse knows the UAPs have understood the teaching if they state that to obtain an accurate measurement of a child's blood pressure, the cuff should cover which portion of the child's upper arm? a. Two-thirds b. Three-fourths c. One-half d. One-third