A nurse is assisting with the care of a client. The nurse is contributing to the plan of care for the client. Which of the following interventions should the nurse include in the plan? Select 5 interventions the nurse should include in the plan.
Explanation & Rationale
A. Teach behavior modification techniques: Educating the client on behavior modification helps them recognize triggers, manage anger, and develop socially acceptable ways to express emotions. This aligns with cognitive-behavioral therapy goals and promotes long-term behavior change. B. Place the client in isolation: This is not indicated unless the client is actively violent or poses imminent danger. Isolation can worsen anger and feelings of rejection. C. Limit client privileges on the unit: Restricting privileges in response to aggressive or destructive behavior provides immediate feedback and reinforces accountability. This intervention sets clear expectations while maintaining safety and therapeutic boundaries. D. Touch the client's arm for reassurance: Never touch an agitated or aggressive client; this may be perceived as threatening and escalate aggression. E. Use nonthreatening body language when addressing the client: Approaching the client calmly with open posture, relaxed tone, and controlled gestures reduces the risk of escalation. Nonthreatening body language fosters a safe therapeutic environment and helps de-escalate anger or aggression. F. Confront the client's aggressive behavior: Confrontation increases defensiveness and may escalate aggression. Therapeutic communication focuses on redirection and de-escalation instead. G. Redirect the client to an appropriate activity: Redirection helps the client manage impulses and engage in safe, structured activities. This approach reduces opportunities for aggression and destructive behavior while promoting participation in therapeutic interventions. H. Role play responses to offensive behavior: Helpful later in therapy, but not appropriate during acute aggression or treatment refusal. The client currently refuses therapy and is unstable; role-play is not a priority intervention at this phase. I. Provide structure and boundaries for the client: Establishing clear rules, routines, and expectations helps the client understand limits and consequences. Structure and consistent boundaries are essential for managing aggression, promoting safety, and supporting behavioral improvement.