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Question
After a nurse addresses an agitated client by setting limits in a calm, direct manner, the client begins pacing, exhibiting a clenched jaw and fists. The nurse would evaluate the approach as ineffective because:1. The nurse lacks rapport with the client.
2. The nurse lacks adequate de-escalation and limit setting skills.
3. Some clients have limited control, so verbal interventions may not work, but this is not reflective of the nurse's skill.
4. In some cases verbal de-escalation and limit setting will not work and the nurse should start with a more restrictive measure.
Answer
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