Practice Quiz

NCLEX-RN

Category - Psychosocial

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A nurse finds a highly agitated male client in the dayroom, swearing and shouting at anyone who tries to get near him. He threatens to hurt anybody who will stop him from getting out of the facility. The nurse’s initial action is to:
  1. Ask the client what is causing his agitation
  2. Ask everyone in the dayroom to get out of the area immediately
  3. Place the client in seclusion
  4. Encourage the client to do deep breathing exercises to calm him down
Explanation
Answer: C - The nurse ensures the safety of the agitated client, the other clients in the facility and the staff members by gathering the staff and placing the client in seclusion. Asking the client what is causing his agitation can further anger the client. Deep breathing is not helpful at this time. Asking everyone in the dayroom to leave may give the client the idea that he is in control.
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