During a night shift on a psychiatric unit, several clients are awake and appear restless and agitated. A nurse notices one client pacing near the nurses’ station, clenching their fists. The client appears visibly tense and avoids eye contact. What intervention should the nurse prioritize to promote a therapeutic environment?
Administer a prescribed sedative to the client to prevent potential violent behavior.
Observe the client discreetly but maintain a distance to avoid provoking them.
Offer the client access to a quiet, private room and avoid addressing their pacing behavior.
Approach the client calmly, use an open posture, and ask if they would like to discuss how they are feeling.
The correct answer involves using therapeutic communication and addressing the client's immediate non-verbal cues that suggest agitation or distress. Approaching the client in a calm and non-threatening manner can de-escalate tension, reduce feelings of isolation, and promote their emotional safety. Offering a quiet space without directly addressing the behavior may overlook the client's need for engagement and support. Administering medications without assessing the client's triggers may miss an opportunity to intervene non-pharmacologically. Avoiding the client entirely can escalate agitation and potentially compromise safety.
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NCLEX RN
Psychosocial Integrity
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