A nurse is caring for a client who is becoming agitated. While attempting to deescalate, which of the following actions should the nurse take first?
Select a quiet location to talk to the client while remaining visible to staff members.
Give the client several clear options.
Observe the client and the situation.
Respect the client's personal space.
The Correct Answer is C
Rationale:
A. Selecting a quiet location is important, but first, it is essential to assess the client's current state and the surrounding environment.
B. Providing options can help empower the client, but it is best to first observe the client to gauge their level of agitation and determine the appropriate response.
C. Observing the client and the situation allows the nurse to understand the severity of the agitation and the context, which is critical for making informed decisions about the next steps.
D. Respecting personal space is important, but it should follow an assessment of the situation to ensure safety for both the client and staff.
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Correct Answer is B
Explanation
Rationale:
A. Cytomegalovirus (CMV) is not nationally notifiable, though it can have significant effects, especially in pregnant women.
B. Foodborne botulism is a nationally notifiable condition due to its potential for widespread outbreaks and severe health consequences.
C. Erythema infectiosum, or fifth disease, is not a nationally notifiable disease, although it is recognized in clinical settings.
D. Herpes simplex virus type 1 (HSV-1) is common and not considered a nationally notifiable infectious disease.
Correct Answer is B
Explanation
Rationale:
A. Sitting with their head in their hands and appearing to cry indicates emotional distress rather than aggression or potential violence.
B. Pacing is often a sign of agitation or anxiety and can be indicative of a potential escalation to violence, especially in individuals with a history of aggressive behavior.
C. While expressing discontent with staff may show frustration, it does not directly indicate imminent violence.
D. Taking numerous, deep breaths may suggest the client is attempting to calm themselves and is not a reliable indicator of potential aggression.