An adult patient assaulted another patient and was subsequently restrained. One hour later, which statement by the restrained patient requires the nurse’s immediate attention?

Choice A rationale
Telling the patient to be quiet and sit down immediately may seem like a quick solution, but it is not the most therapeutic response. This approach may come across as dismissive and authoritarian, which could escalate the patient’s agitation.
Choice B rationale
This is the most appropriate initial intervention. By expressing a desire to understand the patient’s feelings, the nurse opens up a line of communication and shows empathy. This can help de-escalate the situation and make the patient feel heard and understood.
Choice C rationale
Telling the patient to go to their room and control themselves can come across as dismissive and invalidating. It does not address the patient’s feelings or concerns and may escalate the situation.
Choice D rationale
Asking “What is going on?” is a good way to encourage the patient to express their feelings, but it may not be as effective as Choice B. The phrasing in Choice B is more direct and shows more empathy and concern for the patient’s emotional state.

Choice A rationale
While fostering a social relationship can be a part of therapeutic communication, it is not the primary goal. Therapeutic communication in nursing is patient-centered and should involve a holistic approach, including aspects of psychological, physiological, spiritual, and environmental care of the patient.
Choice B rationale
Focusing on the attitude of the client is not the main goal of therapeutic communication. While understanding the client’s attitude can provide valuable insights into their feelings and perspectives, the primary goal is to build a rapport and focus on the client.
Choice C rationale
Focusing on the client and building a rapport is the main goal of therapeutic communication in nursing. It helps nurses build trust with patients while also helping establish collaborative efforts to promote efficient and effective patient care, improving patient outcomes.
Choice D rationale
Focusing on the staff member and building rapport is not the primary goal of therapeutic communication. The focus should be on the client, their needs, and their experiences.