The nurse is observing several patients who are in the activity ...

[shenderson6]

The nurse is observing several patients who are in the activity room of the inpatient psychiatric facility. The nurse notices that one of the patients begins to get upset, raising her voice, pacing the room, and standing with clenched fists.
 
  What is the nurse's priority action?
  1. Reorient the patient to person, place, and time.
  2. Remove other patients from the room to provide more space.
  3. Call the health care provider to obtain an order for anti-anxiety medication.
  4. Call security and promptly isolate the patient and apply physical restraints.

Question 2

The nurse is caring for a patient who appears anxious and is pacing the room and clenching his fists. What action best demonstrates the core concept of effective intervention for this patient?
 
  1. Administering a medication to the patient
  2. Deciding to promptly isolate the patient from others
  3. Assessing the patient's perception of his level of anxiety
  4. Demonstrating therapeutic communication with the patient

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Answer to Question 1

Answer: 2
Explanation: The patient is displaying increased anxiety and aggression. Anxiety and agitation tend to escalate when there is an audience, so removing other patients to another area of the unit is a useful intervention. Removing other patients also provides safety for both the patient who is experiencing anxiety and for the other patients in the room. The patient is not displaying symptoms of altered level of consciousness or disorientation, so the primary nursing action is not to reorient the patient. Calling the health care provider for pharmacological intervention would be appropriate only after the nurse fails to achieve the desired outcome using less restrictive independent interventions. Applying physical restraints is a last resort that would not be used as a primary intervention.

Answer to Question 2

Answer: 4
Explanation: The patient in the scenario is displaying escalating anxiety, which may lead to aggression and violence. Interventions for a patient who is displaying anxiety, frustration, anger, and aggression are based on the core principle of therapeutic communication. Pharmacological therapy may be used in the treatment of this patient; however, this is not the core concept of effective intervention for this patient. While prompt decision-making is appropriate for this patient, isolating the patient is not and does not represent the core concept of effective intervention for this patient. While it may be appropriate to assess the patient's perception of his level of anxiety, this does not represent the core concept of effective intervention for this patient.