Which action should a nurse take when a client with a history of psychosis experiences sudden severe agitation after medication administration?

Choice A reason: Engaging a severely agitated client in a group therapy session is contraindicated and potentially dangerous. High levels of stimulation and the presence of other patients can exacerbate the client's psychosis and agitation, leading to an increased risk of physical aggression or injury to the client and others in the therapeutic environment. Choice B reason: While monitoring vital signs is an important nursing responsibility, recommending rest alone is insufficient for a client experiencing sudden severe agitation. Agitation in a psychotic client often requires active pharmacological intervention to ensure safety and prevent the escalation of behavioral dysregulation that could lead to physical restraint or seclusion. Choice C reason: Administering prescribed benzodiazepines, such as lorazepam, is the standard medical intervention for acute agitation. These medications enhance the effect of the neurotransmitter gamma-aminobutyric acid (GABA) at the GABA-A receptor, resulting in rapid anxiolysis and sedation. This helps to stabilize the client quickly and reduce the risk of violent outbursts. Choice D reason: Instructing a client to use deep breathing exercises is a useful technique for mild anxiety but is generally ineffective during a state of severe, sudden agitation or active psychosis. The client’s cognitive processing and ability to follow complex verbal instructions are significantly impaired during an acute episode, necessitating a more direct pharmacological approach.