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    Ati Lpn Comprehensive Predictor 2023 Proctored Exam

    A nurse is assisting in the care of a client in a mental health facility. During group therapy, the client stands up and starts pacing with their fists clenched. Which of the following actions should the nurse take first?

    Explanation & Rationale

    A. Administer haloperidol via the intramuscular route: Haloperidol can help manage agitation in clients with psychiatric conditions, but administering medication before assessing the client’s emotional state bypasses the nursing process. Immediate pharmacologic intervention should follow a thorough assessment. B. Move the client into the seclusion room: Seclusion is a restrictive intervention used to prevent harm, but it is not the first step. The nurse should first assess the client’s behavior and emotional triggers before implementing restrictive measures. C. Collect data regarding the client's feelings: Assessing the client’s emotional state and triggers allows the nurse to identify the cause of agitation and select the least restrictive, most appropriate intervention. Data collection guides clinical decision-making and promotes safety while respecting client autonomy. D. Obtain assistance to apply wrist restraints: Physical restraints are a last-resort intervention used only when the client poses an immediate risk to self or others. Applying restraints before assessment violates safety protocols and therapeutic principles.

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