A client who has been seen responding to auditory hallucinations earlier in the morning approaches
the nurse and shakes his fist, saying Back off, bitch and then goes into the day room.
The nurse
goes into the day room. The client continues to mumble and shake his fist. The nursing actions most
likely to be effective in achieving the outcome of de-escalation would be (more than one answer
may be correct)
A. telling the client that he is behaving inappropriately.
B. stating the client cannot be understood when he mumbles.
C. stating the expectation that the client will stay in control.
D. offering to provide the client with as-needed medication.
Question 2
The nurse psychotherapist looks at the records of the clients admitted over the weekend to determine
whom to include in the inpatient symptom management group focusing on self-esteem issues.
Which
client will the nurse consider inappropriate to bring into the group?
a. A, aged 32 years, a client with chronic paranoid schizophrenia
b. B, aged 59 years, a client with depression
c. C, aged 22 years, a client with panic disorder
d. D, aged 30 years, a client with antisocial personality disorder
Client position when assessing jugular vein distention.
A nurse prepares a client for anesthesia and surgery.
The Auditory Cortex
Use face cradle covers to prevent the client’s skin from touching the face cradle upholstery.
A hot stone placed under the client’s neck.
Client and therapist positioning for foot reflexology.