A nurse is caring for a client who is visibly agitated and talking loudly in a group therapy session. Which of the following actions should the nurse take first?

Place the client in seclusion.

Assist the client with understanding their needs.

Ask the client to identify what made them upset.

Administer lorazepam IM.

Answer and Explanation

The Correct Answer is C

Choice A reason: Seclusion is a last resort, not first, per de-escalation principles. It risks escalating agitation or trauma without addressing the cause. Scientifically, verbal intervention precedes restraint, as identifying triggers can calm the client, aligning with evidence-based psychiatric care prioritizing least restrictive measures.

Choice B reason: Assisting with needs is vague and secondary to identifying the agitation’s source. Without understanding the trigger, this lacks focus. Scientifically, pinpointing the upset first guides effective support, making this a follow-up, not initial, step in managing acute behavioral distress.

Choice C reason: Asking what upset the client de-escalates by engaging them, identifying triggers for targeted intervention. This aligns with scientific psychiatric practice, reducing agitation through communication before medication or seclusion, addressing the root cause effectively as the first step in evidence-based care.

Choice D reason: Administering lorazepam IM is premature without de-escalation attempts. It risks over-sedation or side effects, bypassing verbal strategies. Scientifically, medication follows failed non-pharmacological efforts per guidelines, making this a later option, not the first, in managing agitation safely and effectively.

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Correct Answer is D

Explanation

Choice A reason: Being married with children often buffers suicide risk by providing social support and purpose, reducing isolation—a key factor in depression. Scientifically, strong familial ties correlate with lower rates, making this a protective, not risk-enhancing, element in mental health assessments.

Choice B reason: Strong religious affiliation typically lowers suicide risk, as faith offers coping mechanisms and community, countering despair. Scientifically, studies show religiosity inversely relates to suicide, acting as a protective factor, not a contributor, in depression-related risk evaluations.

Choice C reason: A recent pay raise suggests improved financial stability, reducing stress—a suicide risk factor. Positive life events like this bolster resilience in depression, not heighten risk. Scientifically, this aligns with lower suicidal ideation, making it a protective rather than aggravating circumstance.

Choice D reason: Chronic back pain increases suicide risk in depression, as persistent pain erodes quality of life, amplifying hopelessness. Scientifically, chronic conditions correlate with higher rates, as physical suffering compounds psychological distress, making this a significant risk factor per mental health research.

A. "Let me explain the pros and cons of your decision." B. "I will support your decision and help you explain it to others." C. "I will send the social worker in to discuss this decision with you." D. "I suggest you discuss this decision with your family first."

Correct Answer is B

Explanation

Choice A reason: Explaining pros and cons informs but may pressure the client. Supporting autonomy respects their choice, aligning with lung cancer end-of-life preferences better.

Choice B reason: Supporting the client’s DNR decision upholds autonomy and aids communication. In lung cancer, respecting end-of-life wishes is critical, making this the best response.

Choice C reason: Involving a social worker delegates support, not directly honoring the client’s wish. Nurses should first affirm autonomy in such terminal cancer scenarios.

Choice D reason: Suggesting family discussion undermines autonomy, adding burden. The client’s decision in advanced cancer should be respected without implying external validation needs.

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A nurse is caring for a client who is visibly agitated and talking loudly in a group therapy session. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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