A nurse is caring for a client in a mental health facility. The client is agitated and threatens to harm themselves and others. Which of the following is the priority intervention?
Administer an anxiolytic to the client.
Set limits on the client's behavior.
Place the client in restraints.
Put the client in seclusion.
The Correct Answer is B
Choice A reason: Administering medication may help reduce agitation, but it is not the first-line intervention in an acute crisis. Medication takes time to act and does not immediately address the safety threat. It is more appropriate after initial de-escalation efforts have failed or in conjunction with other strategies.
Choice B reason: Setting limits is the least restrictive and most immediate intervention to ensure safety. It helps establish boundaries, reduce escalation, and maintain control of the situation. This aligns with psychiatric nursing principles that prioritize safety while preserving autonomy and dignity.
Choice C reason: Restraints are considered a last resort due to their physical and psychological risks. They should only be used when all other interventions have failed and there is imminent danger to the client or others.
Choice D reason: Seclusion is also a restrictive intervention and should only be used when less restrictive measures are ineffective. It may be necessary in some cases, but it is not the priority unless the client cannot be managed safely through verbal de-escalation and limit-setting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Difficulty recognizing objects (agnosia) is expected in dementia progression and does not require immediate reporting unless it leads to safety concerns.
Choice B reason: Loss of interest (anhedonia) is a hallmark of depression but not an acute change requiring urgent intervention unless accompanied by suicidal ideation.
Choice C reason: Rapid weight gain may indicate metabolic syndrome or fluid retention, but without other symptoms, it is not immediately life-threatening.
Choice D reason: Decreased urine output in a client on lithium may signal nephrotoxicity or lithium toxicity. This is a potentially life-threatening complication requiring prompt evaluation.
Correct Answer is A
Explanation
Choice A reason: Assisting with self-care needs such as hygiene, dressing, and feeding is within the scope of practice for assistive personnel. These tasks do not require clinical judgment and support the client’s daily functioning.
Choice B reason: Monitoring for command hallucinations requires clinical assessment and interpretation, which must be performed by a licensed nurse. It involves evaluating risk and safety concerns.
Choice C reason: Reinforcing teaching involves understanding the care plan and evaluating client comprehension, which is outside the scope of assistive personnel. It requires nursing knowledge and judgment.
Choice D reason: Exploring a client’s feelings is part of therapeutic communication and requires advanced interpersonal skills and clinical insight. This is a nursing responsibility and cannot be delegated.
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