Practice Question
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.)
Answer Choices:
Correct Answer:
Identify the client's stressors.
Rationale:
🟣Agitation and pacing often result from underlying triggers such as fear, frustration, or unmet needs.
🟣Identifying stressors allows the nurse to address the root cause of the agitation, which can help de-escalate the situation.
🟣This demonstrates therapeutic communication and supports client-centered care.
🟣 Talk to the client using short, simple sentences During agitation, the client may have impaired concentration and decreased ability to process complex information.
🟣Using clear, concise statements reduces misinterpretation and helps prevent further escalation.
🟣Simple communication also conveys a calm and controlled presence, which is essential for de-escalation.
🟣The nurse should use nonthreatening, therapeutic interventions first to de-escalate behavior.
🟣Standing directly in front, yelling, or restraining the client can escalate aggression and should not be the initial approach.
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This question is from RN Mental Health 2023 B which contains 65 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Mental Health
- Answer Choices: 5