A nurse is caring for multiple clients on a mental health unit.Which of the following clients should the nurse attend to first?
Explanation & Rationale
Choice A rationaleA client repeatedly requesting anxiety medication should be assessed, but their behavior does not indicate an immediate safety risk to themselves or others. While their anxiety needs attention, other clients may have more urgent needs. The nurse should acknowledge their request and address it in a timely manner, but not necessarily as the absolute first priority.Choice B rationaleA client yelling obscenities and throwing clothes is exhibiting escalating and potentially aggressive behavior. This situation poses an immediate risk to the client's safety and the safety of others on the unit. The nurse must intervene promptly to de-escalate the situation, ensure the client's well-being, and prevent potential harm to themselves or others. This behavior indicates a loss of control and requires immediate attention.Choice C rationaleA client with bipolar disorder who is continuously pacing is displaying psychomotor agitation, which is characteristic of a manic episode. While this behavior warrants assessment and intervention, it does not present the same level of immediate risk as the client who is actively yelling and throwing objects. The pacing client should be monitored and offered interventions to help manage their agitation, but they are not the highest priority in this scenario.Choice D rationaleA client screaming at other clients in the dayroom is exhibiting aggressive verbal behavior that is disruptive and potentially threatening to others. This situation requires the nurse's intervention to de-escalate the situation, ensure the safety and comfort of the other clients, and address the yelling client's behavior. However, the client actively throwing objects in their room poses a more immediate and direct safety risk.