Practice Question
A client is becoming increasingly agitated, anxious, and tense. The nurse notes a clenched jaw and a change in the pitch of the client's voice. Which of the following interventions should the nurse implement first?
Answer Choices:
Correct Answer:
Verbally de-escalate the client.
Rationale:
💎 The first-line intervention for a client showing early signs of agitation (e.g., clenched jaw, anxious tone, increased tension) is verbal de-escalation.
💎 This involves using calm, clear, and non-threatening communication to help the client regain control before behavior escalates to violence.
💎 Early intervention with therapeutic communication can prevent the need for restrictive measures such as restraints or seclusion.
💎 Medications (e.g., haloperidol) and seclusion are used only when the client becomes a danger to self or others and less restrictive methods have failed.
💎 De-escalation preserves the client’s dignity and autonomy while maintaining safety.
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This question is from ATI LPN MENTAL HEALTH 2023 which contains 51 questions.
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Question Details
- Category: LPN Nursing Exam(s)
- Subcategory: LPN ATI Exams
- Domain: Mental Health
- Answer Choices: 4