A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply.)
Identify the client's stressors.
Talk to the client using short, simple sentences.
Speak to the client in a loud voice.
Request that security guards restrain the client.
Stand directly in front of the client.
Correct Answer : A,B
Choice A reason: Identifying the client's stressors is a crucial step in managing agitation. Understanding what triggers the client's distress can help the nurse to address the underlying issues and de-escalate the situation.
Choice B reason: Using short, simple sentences can help to communicate effectively with an agitated client. It ensures that the client can process the information without being overwhelmed, which is important for calming the situation.
Choice C reason: Speaking to the client in a loud voice is not recommended as it may escalate the situation. It's important to maintain a calm and soothing tone to avoid further agitation.
Choice D reason: Requesting that security guards restrain the client should be a last resort, only if the client poses an immediate threat to themselves or others. Less restrictive measures should be attempted first.
Choice E reason: Standing directly in front of an agitated client can be perceived as confrontational. It's better to maintain a non-threatening stance and ensure there is enough space to allow the client to feel safe.
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Correct Answer is B
Explanation
Choice A reason: This response may seem dismissive and could minimize the client's feelings. It's important to acknowledge the client's emotions as valid and unique to their experience, rather than comparing them to others.
Choice B reason: This response invites the client to share their feelings in a non-judgmental space and shows the nurse's willingness to listen. It respects the client's autonomy and provides an opportunity for them to open up about their concerns at their own pace.
Choice C reason: While this response is meant to be reassuring, it may inadvertently invalidate the client's feelings. Embarrassment is a personal emotion, and what might seem trivial to one person can be significant to another.
Choice D reason: This response implies that sharing will lead to relief, which may not always be the case. It also puts pressure on the client to disclose information before they are ready, which could be counterproductive.
Correct Answer is D
Explanation
Choice A reason: Providing reassurance and comfort through touch can be beneficial in some cases; however, for clients experiencing command hallucinations, physical touch may be misinterpreted and could potentially escalate the situation. It's essential to gauge the client's comfort level with touch and proceed cautiously.
Choice B reason: While socialization is an important aspect of recovery, for a client experiencing command hallucinations, group therapy might be overwhelming and could exacerbate the hallucinations. It's crucial to introduce socialization gradually and in a controlled environment.
Choice C reason: Eye contact can be perceived as threatening or confrontational by clients with schizophrenia, especially when experiencing command hallucinations. It's important to respect the client's space and use non-confrontational body language to communicate effectively.
Choice D reason: Maintaining a low level of environmental stimuli is crucial for clients experiencing command hallucinations. A calm and quiet environment can help reduce the intensity and frequency of hallucinations, providing a sense of safety and reducing stress and anxiety.
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