Alzheimer’s Delirium and Dementia Q 35
Which nursing action is most appropriate when trying to diffuse a client’s impending violent behavior?
A. Place the client in seclusion.
B. Leaving the client alone until he can talk about his feelings.
C. Involving the client in a quiet activity to divert attention.
D. Helping the client identify and express feelings of anxiety and anger.
Correct Answer: D. Helping the client identify and express feelings of anxiety and anger
In many instances, the nurse can diffuse impending violence by helping the client identify and express feelings of anger and anxiety. Such statements as “What happened to get you this angry?” may help the client verbalize feelings rather than act on them. Frequently assess client’s behavior for signs of increased agitation and hyperactivity. Early detection and intervention of escalating mania will prevent the possibility of harm to self or others, and decrease the need for seclusions.
Option A: Alert staff if a potential for seclusion appears imminent. Usual priority of interventions would be: firmly setting limits; chemical restraints (tranquilizers); or seclusion. If nursing interventions (quiet environment and firm limit setting) and chemical restraints (tranquilizers–e.g., haloperidol [Haldol]) have not helped dampen escalating manic behaviors, then seclusion might be warranted.
Option B: Maintain a consistent approach, employ consistent expectations, and provide a structured environment. Clear and consistent limits and expectations minimize potential for client’s manipulation of staff. Remain neutral as possible; Do not argue with the client. The client can use inconsistencies and value judgments as justification for arguing and escalating mania.
Option C: Redirect agitation and potentially violent behaviors with physical outlets in an area of low stimulation (e.g., punching bag); can help to relieve pent-up hostility and relieve muscle tension. Decrease environmental stimuli (e.g., by providing a calming environment or assigning a private room); helps decrease escalation of anxiety and manic symptoms.