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    ATI 133 Mental Health Final Proctored Exam

    A nurse on a mental health unit notices that a client is becoming increasingly agitated and throws a table when he is unable to select the television (TV) channel. Which of the following should be the priority action by the nurse?

    Explanation & Rationale

    Choice A reason:Placing the client in a monitored seclusion room is a restrictive intervention that should be used only when less restrictive measures have failed and the client cannot be safely managed by other means. It is not the first line of action due to the potential negative psychological impact on the client.Choice B reason:Attempting to talk the client down is the first and preferred approach. It involves using de-escalation techniques to calm the client, which can include speaking in a calm, non-threatening tone, actively listening to the client's concerns, and offering reassurance. This non-pharmacological intervention aligns with best practice recommendations for managing mild to moderate agitation.Choice C reason:Physical restraint is a last resort and should only be used when the client poses an immediate risk to themselves or others and when all other interventions have been unsuccessful. Restraints can have significant psychological effects and should be avoided whenever possible.Choice D reason:Administering a PRN antianxiety medication may be appropriate if the client is prescribed such medication and if verbal de-escalation is not effective. However, it should not be the first action taken as non-pharmacological interventions are preferred initially.

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