Practice Question
The nurse notices a client with bipolar disorder is escalating and is becoming very agitated. Which nursing intervention is most appropriate?
Answer Choices:
Correct Answer:
Provide the client with adequate personal space.
Rationale:
🟡 In clients with bipolar disorder experiencing escalation or agitation, maintaining adequate personal space is essential to reduce perceived threats and help prevent aggressive outbursts. Respecting personal boundaries can de-escalate tension and promote a sense of safety for both the client and staff.
🟡 Approaching too closely or making physical contact when the client is highly agitated may be interpreted as confrontational or intrusive, potentially triggering aggressive behavior.
🟡 Maintaining non-threatening body language, a calm tone, and safe physical distance supports a therapeutic environment and allows the nurse to intervene effectively while minimizing risk.
🟡 This approach is consistent with de-escalation techniques in psychiatric care, which prioritize safety, reduce stimulation, and avoid power struggles during episodes of agitation.
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This question is from Examplify Mental Health 1 which contains 56 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Mental Health
- Answer Choices: 4