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    Ati rn 400 mental health final proctored exam

    A nurse in an acute mental health facility is caring for a client who jumps out of her chair and begins to shout angrily at the clients around her. Which of the following actions should the nurse take first?

    Explanation & Rationale

    A. Offering PRN medication can be considered, but it is not the first action. It is important to attempt de-escalation strategies before considering medication. B. Escorting the client to a seclusion room is a more extreme measure and should be considered after attempts to de-escalate the situation have failed. C. Restraints should only be used as a last resort after all other de-escalation techniques have been exhausted and if there is a risk of harm to the client or others. D. The first priority should be to speak to the client calmly and give simple directions. This approach aims to de-escalate the situation and reduce the client’s agitation in a non-confrontational manner.

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