11. A client, who has had several verbal outbursts and is pacing around a psychiatric unit, is at risk for assaultive behavior. Which verbal response by a nurse is most appropriate?
11. A client, who has had several verbal outbursts and is pacing around a psychiatric unit, is at risk for assaultive behavior. Which verbal response by a nurse is most appropriate?
. "Do not get agitated; everything is safe here."
. "Please take a time-out in your room."
. "If you don't follow the rules, you will be put in seclusion."
. "Let me take your blood pressure. I think you are having a lot of anxiety."
Test-Taking Tip
As anxiety levels increase, the client's ability to process information decreases. Choose the most specific intervention. Eliminate the two "negative" options (Answer 1 "not", Answer 3 "don't").
Content Area: Mental Health, Anxiety; Integrated Process: Communication and Documentation; Cognitive Level: Application; Client Need/Subneed: Psychosocial Integrity/Mental Health Concepts
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Answer 1 is incorrect because the nurse is offering false reassurance. Answer 2 is correct because, at the client's increasing level of anxiety, the client can only understand simple, short phrases. Answer 3 is incorrect because the nurse's response is inappropriate because it challenges the client and is threatening. Answer 4 is incorrect because the nurse's response is inappropriate because it doesn't address the verbal outburst, and the action of taking the client's blood pressure places the nurse's safety at risk.