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?

Verbally de-escalate the client.

Take the client to the seclusion room.

Place the client in restraints.

Obtain a prescription for haloperidol.

Answer and Explanation

The Correct Answer is A

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Correct Answer is B

Explanation

Choice A rationale

Preoccupation with details is more characteristic of obsessive-compulsive personality disorder, where individuals focus excessively on rules, order, and details.

Choice B rationale

Manipulative behaviors are a common finding in individuals with antisocial personality disorder. These individuals often use manipulation to gain control or achieve their own goals without regard for others.

Choice C rationale

Impulsiveness is a characteristic of many personality disorders but is particularly prevalent in antisocial personality disorder, where individuals often act without considering the consequences.

Choice D rationale

Splitting is a defense mechanism more commonly associated with borderline personality disorder, involving an inability to integrate positive and negative aspects of oneself or others.

A. A client who is repeatedly approaching the nurses' station to request medication for his anxiety. B. A client who is standing in her room, yelling obscenities, and throwing her clothes. C. A client who has bipolar disorder and is continuously pacing at the end of the hall. D. A client in the dayroom who is screaming at other clients about what is on the television.

Correct Answer is B

Explanation

Choice A rationale

While this client may need attention, the behavior is not immediately dangerous.

Choice B rationale

This client requires immediate attention due to the risk of harm to herself and others through throwing objects and yelling, which indicates potential for escalation.

Choice C rationale

Pacing, although concerning, does not pose an immediate risk of physical harm compared to Choice B.

Choice D rationale

The client is disruptive but not immediately dangerous compared to the client in Choice B who poses a more direct risk.

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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?

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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?