A nurse on a mental health unit is caring for a client who is becoming increasingly agitated, pacing the hallways, and clenching their fists. Which of the following actions by the nurse is the most appropriate initial intervention?
Continue to observe the client from a distance and ignore the behavior.
Administer the client's prescribed PRN lorazepam.
Firmly tell the client to stop pacing and return to their room.
Invite the client to the gym for a basketball game.
The correct intervention is inviting the client to the gym for a basketball game, which is an example of redirection. This behavioral management technique helps the client channel their agitation and aggressive feelings into a safe and constructive physical activity. Administering PRN medication is a more restrictive intervention and should be considered only after attempts at de-escalation have failed. Firmly telling the client to stop their behavior is confrontational and likely to escalate the agitation. Ignoring the behavior is inappropriate as the client's actions indicate a risk for violence that requires intervention to ensure safety.
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Why should PRN medication not be the first step in de-escalating agitation?
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Why is a confrontational approach, like firmly telling the client to stop pacing, not effective?
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NCLEX RN
Psychosocial Integrity
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