A nurse is caring for a client who is visibly agitated and talking loudly in a group therapy session. Which of the following actions should the nurse take first?

Choice A reason: Voice alteration isn’t linked to ECT; it affects brain function, not vocal cords. Post-procedure, neurological effects dominate, not laryngeal changes.

Choice B reason: Neck pain may occur from positioning, but it’s not a primary ECT reaction. Muscle relaxants minimize strain, making this less common.

Choice C reason: Scalp tingling could stem from electrodes, but it’s rare and minor. ECT’s electrical impact targets memory and mood, not sensory nerves.

Choice D reason: Temporary memory loss is a well-documented ECT side effect, from disrupted hippocampal function. It’s expected, often resolving, and key to inform clients.

Choice A reason: Seclusion is a last resort, not first, per de-escalation principles. It risks escalating agitation or trauma without addressing the cause. Scientifically, verbal intervention precedes restraint, as identifying triggers can calm the client, aligning with evidence-based psychiatric care prioritizing least restrictive measures.

Choice B reason: Assisting with needs is vague and secondary to identifying the agitation’s source. Without understanding the trigger, this lacks focus. Scientifically, pinpointing the upset first guides effective support, making this a follow-up, not initial, step in managing acute behavioral distress.

Choice C reason: Asking what upset the client de-escalates by engaging them, identifying triggers for targeted intervention. This aligns with scientific psychiatric practice, reducing agitation through communication before medication or seclusion, addressing the root cause effectively as the first step in evidence-based care.

Choice D reason: Administering lorazepam IM is premature without de-escalation attempts. It risks over-sedation or side effects, bypassing verbal strategies. Scientifically, medication follows failed non-pharmacological efforts per guidelines, making this a later option, not the first, in managing agitation safely and effectively.