Crisis Intervention And De-Escalation - NCLEX-PN
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What is the recommended stance and positioning during de-escalation to reduce perceived threat?
What is the recommended stance and positioning during de-escalation to reduce perceived threat?
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Stand at an angle with an exit route and hands visible. This positioning minimizes confrontation, ensures escape options, and promotes trust through non-threatening body language.
Stand at an angle with an exit route and hands visible. This positioning minimizes confrontation, ensures escape options, and promotes trust through non-threatening body language.
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Which communication technique validates feelings without agreeing to unsafe behavior?
Which communication technique validates feelings without agreeing to unsafe behavior?
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Empathic reflection (validation) with limit setting. This technique builds rapport by acknowledging emotions while firmly establishing boundaries against unsafe actions.
Empathic reflection (validation) with limit setting. This technique builds rapport by acknowledging emotions while firmly establishing boundaries against unsafe actions.
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Identify the best action when a patient is escalating: reduce stimuli or increase staff crowding?
Identify the best action when a patient is escalating: reduce stimuli or increase staff crowding?
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Reduce stimuli. Reducing stimuli decreases sensory overload, which can exacerbate agitation and hinder de-escalation efforts.
Reduce stimuli. Reducing stimuli decreases sensory overload, which can exacerbate agitation and hinder de-escalation efforts.
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What is the best way to give directions to an agitated patient to support compliance?
What is the best way to give directions to an agitated patient to support compliance?
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Use short, simple, one-step instructions. Simple instructions match the patient's reduced cognitive capacity during agitation, enhancing understanding and compliance.
Use short, simple, one-step instructions. Simple instructions match the patient's reduced cognitive capacity during agitation, enhancing understanding and compliance.
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Which patient behavior is an early warning sign of potential violence?
Which patient behavior is an early warning sign of potential violence?
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Pacing with clenched fists and increasing agitation. These nonverbal cues indicate rising tension and potential for aggression, allowing early intervention.
Pacing with clenched fists and increasing agitation. These nonverbal cues indicate rising tension and potential for aggression, allowing early intervention.
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What is the best practice regarding personal space during de-escalation?
What is the best practice regarding personal space during de-escalation?
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Respect personal space and avoid sudden movements or touch. Maintaining space respects boundaries, reduces paranoia, and prevents escalation from perceived threats.
Respect personal space and avoid sudden movements or touch. Maintaining space respects boundaries, reduces paranoia, and prevents escalation from perceived threats.
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Which intervention is least restrictive: verbal de-escalation, seclusion, or restraints?
Which intervention is least restrictive: verbal de-escalation, seclusion, or restraints?
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Verbal de-escalation. Verbal methods preserve patient autonomy and dignity, aligning with least restrictive intervention principles.
Verbal de-escalation. Verbal methods preserve patient autonomy and dignity, aligning with least restrictive intervention principles.
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What is the correct sequence of interventions for escalating behavior (least to most restrictive)?
What is the correct sequence of interventions for escalating behavior (least to most restrictive)?
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Verbal de-escalation → medications → seclusion/restraints as last resort. This progression adheres to ethical standards by starting with non-invasive options and escalating only as necessary for safety.
Verbal de-escalation → medications → seclusion/restraints as last resort. This progression adheres to ethical standards by starting with non-invasive options and escalating only as necessary for safety.
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What is the most appropriate action if de-escalation fails and imminent harm is likely?
What is the most appropriate action if de-escalation fails and imminent harm is likely?
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Initiate emergency response and use restraints/seclusion per protocol. When harm is imminent, protocols authorize restrictive measures to protect all parties after less invasive options fail.
Initiate emergency response and use restraints/seclusion per protocol. When harm is imminent, protocols authorize restrictive measures to protect all parties after less invasive options fail.
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What must be documented after any crisis intervention or restraint/seclusion event?
What must be documented after any crisis intervention or restraint/seclusion event?
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Behaviors, interventions tried, patient response, and ongoing monitoring. Comprehensive documentation ensures legal compliance, continuity of care, and evaluation of intervention effectiveness.
Behaviors, interventions tried, patient response, and ongoing monitoring. Comprehensive documentation ensures legal compliance, continuity of care, and evaluation of intervention effectiveness.
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What is the priority nursing assessment during and after restraint use?
What is the priority nursing assessment during and after restraint use?
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Airway, breathing, circulation, and neurovascular status. These assessments monitor for complications like asphyxia or injury, ensuring patient safety during restrictive interventions.
Airway, breathing, circulation, and neurovascular status. These assessments monitor for complications like asphyxia or injury, ensuring patient safety during restrictive interventions.
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Which statement best sets a behavioral limit for an agitated patient without provoking?
Which statement best sets a behavioral limit for an agitated patient without provoking?
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“You may be angry, but you may not hit; we will talk in a quiet area.”. This phrasing validates emotions while clearly prohibiting violence and redirecting to a calmer setting.
“You may be angry, but you may not hit; we will talk in a quiet area.”. This phrasing validates emotions while clearly prohibiting violence and redirecting to a calmer setting.
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What is the key principle of trauma-informed de-escalation during a crisis?
What is the key principle of trauma-informed de-escalation during a crisis?
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Promote choice, collaboration, and a sense of safety and control. Trauma-informed care emphasizes empowerment and safety to avoid re-traumatization during vulnerable states.
Promote choice, collaboration, and a sense of safety and control. Trauma-informed care emphasizes empowerment and safety to avoid re-traumatization during vulnerable states.
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What is the appropriate post-crisis intervention after the patient is calm and safe?
What is the appropriate post-crisis intervention after the patient is calm and safe?
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Conduct a debrief to identify triggers and plan coping strategies. Debriefing facilitates learning from the event, preventing future crises through trigger identification and strategy development.
Conduct a debrief to identify triggers and plan coping strategies. Debriefing facilitates learning from the event, preventing future crises through trigger identification and strategy development.
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What is the best initial action if a patient has a weapon or you suspect one is present?
What is the best initial action if a patient has a weapon or you suspect one is present?
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Increase distance, leave if needed, and call security immediately. Increasing distance and calling security minimizes risk of injury while prioritizing immediate safety protocols.
Increase distance, leave if needed, and call security immediately. Increasing distance and calling security minimizes risk of injury while prioritizing immediate safety protocols.
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