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    Ati rn mental health 2023 proctored exam retake 1

    A nurse is leading a group therapy session. A client with a history of violence suddenly stands up and appears angry. Which of the following actions should the nurse take?

    Explanation & Rationale

    A. Place the client in mechanical restraints: Restraints should only be used as a last resort and only when the client poses an immediate risk to themselves or others. The first priority should be to try to de-escalate the situation verbally. B. Ask the client to describe how they are feeling: This is the most appropriate intervention. Asking the client to express their emotions helps acknowledge their feelings and can de-escalate the situation. This approach is non-threatening and allows the nurse to assess the client's state and intervene appropriately. C. Stand directly in front of the client when speaking to them: Standing directly in front of the client can be perceived as confrontational, especially when the client is angry. It is better to stand at an angle to the client, maintaining a non-threatening stance. D. Use therapeutic touch when addressing the client: Therapeutic touch may escalate the situation, especially if the client is already angry. It is important to maintain a safe distance and avoid physical contact until the client’s emotional state is more stable.

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