NCLEX RN Practice Question

The correct answer is to approach the client and use therapeutic communication. The client's non-verbal cues (pacing, avoiding eye contact, tension) strongly suggest psychological distress, such as anxiety. The nurse's first priority is to assess the client's feelings and the source of the distress using therapeutic, open-ended communication. Documenting is important but is not the first action. Administering a PRN medication is premature without a thorough assessment of the client's current state. Directing the client back to their room is a non-therapeutic response that dismisses the client's needs and may escalate their agitation.