A nurse is preparing to assess an older client who is new to a medical-surgical unit. Upon entry to the client’s room, the nurse observes that the client answers questions appropriately but falls back to sleep immediately after their responses. Which of the following best describes the client’s level of consciousness?

Choice A Reason:

Assist the client to identify triggers or sources of stress.

This is the correct response. Before educating clients about relaxation techniques, it is essential to help them identify their specific triggers or sources of stress. Understanding what causes their stress allows for more tailored and effective relaxation strategies. This step ensures that the relaxation techniques taught are relevant and can directly address the client’s needs, leading to better outcomes in managing anxiety and stress.

Choice B Reason:

Educate the client’s family so they can be active participants in the therapy.

While involving the client’s family in therapy can be beneficial, it is not the primary action to take before educating the client about relaxation techniques. Family education can support the client’s overall treatment plan, but the initial focus should be on understanding the client’s individual stressors and needs.

Choice C Reason:

Perform a physical assessment to ensure the client is able to participate in this therapy.

Performing a physical assessment is important to ensure the client can safely participate in relaxation techniques. However, this step is secondary to identifying the client’s stress triggers. Once the triggers are identified, the nurse can then assess the client’s physical ability to engage in specific relaxation exercises.

Choice D Reason:

Obtain an order from the psychiatrist during the treatment team.

Obtaining an order from the psychiatrist may be necessary for certain interventions, but it is not typically required for teaching relaxation techniques. The nurse can independently educate clients on these techniques as part of standard nursing care for managing stress and anxiety.

Choice A Reason:

Encouraging social interaction might not be appropriate in this situation. The client’s bizarre behavior is already causing distress to others, and encouraging more interaction could exacerbate the problem. The priority should be to address the immediate safety and well-being of both the client and others. Once the client is in a safe environment, social interaction can be encouraged in a controlled and therapeutic manner.

Choice B Reason:

Discussing the bizarre behavior with the client might not be effective in the moment, especially if the client is not in a state to understand or engage in such a discussion. The primary focus should be on ensuring safety and stability before addressing specific behaviors. Once the client is calm and in a safe environment, discussions about behavior can be more productive.

Choice C Reason:

Providing information about the client’s illness is important for long-term management and understanding, but it is not the immediate priority in this situation. The client’s current state requires immediate intervention to ensure safety. Education about the illness can be provided once the client is stabilized and in a better position to comprehend the information.

Choice D Reason:

Providing a safe environment is the most immediate and crucial priority. The client’s behavior is not only distressing to others but could also pose a risk to herself and others. Ensuring the client is in a safe, controlled environment helps to prevent harm and allows for further assessment and appropriate interventions. Safety is always the first priority in managing acute behavioral disturbances.