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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: The orientation phase focuses on establishing trust, defining roles, and setting goals collaboratively. This sets the foundation for therapeutic engagement.
Choice B reason: Teaching problem-solving skills is more appropriate during the working phase when interventions are actively implemented.
Choice C reason: Incorporating strategies into daily life occurs later in the relationship, typically during the working or termination phase.
Choice D reason: Evaluation of coping mechanisms is part of the working or termination phase, not the initial orientation phase.

A. Assume authority by standing directly in front of the client. B. Attempt to calm the client with therapeutic touch. C. Offer the client a PRN medication to reduce their anxiety. D. Recruit other staff members to talk the client down.

Correct Answer is C

Explanation

Choice A reason: Standing directly in front of an aggressive client can be perceived as confrontational and escalate the situation. Staff should maintain a safe distance and non-threatening posture.

Choice B reason: Therapeutic touch is contraindicated in aggressive situations. Physical contact may provoke further aggression or be misinterpreted.

Choice C reason: Offering PRN medication is a safe and effective de-escalation strategy. It helps reduce agitation and prevent escalation when used appropriately.

Choice D reason: Bringing multiple staff members may overwhelm or intimidate the client. It should only be done if safety is compromised and intervention is necessary.

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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?

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