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A client in the psychiatric unit's dayroom is becoming agitated, talking incessantly, and starting to yell and swear at the other clients.

Which action should the practical nurse (PN) implement first?

A.

Instruct an unlicensed assistive personnel (UAP) to stay with the client.

B.

Notify the client's healthcare provider

C.

Administer an as needed (PRN) medication for agitation

D.

Escort the client to a calm and quiet place.

Answer and Explanation

The Correct Answer is D

d. Escort the client to a calm and quiet place.

The PN should use a calm and firm approach to de-escalate the situation and remove the client from the stressful environment. This can help prevent further agitation and potential violence.

The other options are not correct because:

  1. Instructing a UAP to stay with the client may not be effective or safe, as the UAP may not have the skills or training to handle an agitated client.
  2. Notifying the client's healthcare provider is not a priority action, as it does not address the immediate safety of the client and others.
  3. Administering a PRN medication for agitation may be indicated, but it is not the first action. The PN should try non- pharmacological interventions first, unless there is an imminent risk of harm.


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Related Questions

Correct Answer is D

Explanation

The correct answer is Choice D. What are the voices uttering?

Choice A rationale:

While it is essential to assess how the client copes with auditory hallucinations, asking this question alone does not provide specific information about the content of the hallucinations. Knowing what the voices are saying is vital in understanding the nature and potential impact of the hallucinations.

Choice B rationale:

Knowing when the voices are most disturbing can provide some insights into the pattern of the auditory hallucinations. However, this information alone may not fully address the client's current experience or their response to the hallucinations.

Choice C rationale:

Inquiring about which medication works best is important, but it should come after understanding the nature of the hallucinations. Medication management is a crucial aspect of treating schizophrenia, but gathering information about the content of the hallucinations helps in formulating an appropriate treatment plan.

Choice D rationale:

The correct choice. Knowing what the voices are uttering is essential in assessing the severity and potential impact of the auditory hallucinations on the client's well-being. This information will guide the healthcare team in providing targeted interventions and support to manage the symptoms effectively.

Correct Answer is D

Explanation

This comment shows empathy, respect, and support for the client, without being intrusive or judgmental. The PN acknowledges the client's feelings and offers companionship, which can help reduce isolation and loneliness.

The other options are not correct because:

A. This comment may be perceived as coercive or dismissive of the client's feelings, as it tries to persuade the client to do something he does not want to do or enjoy.

B. This comment may be perceived as accusatory or interrogatory, as it questions the client's decision or motive for staying in his room.

C. This comment may be perceived as minimizing or invalidating the client's feelings, as it implies that the client should not be sad or that his family is doing enough for him.

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