Level: Advanced
Difficulty: Hard
Subtopic: Milieu safety
NCLEX: A client in an inpatient psychiatric unit begins pacing aggressively and clenching fists. What is the priority nu…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A client in an inpatient psychiatric unit begins pacing aggressively and clenching fists. What is the priority nursing action?
Question
A. Maintain a safe distance, remove hazardous items, and follow de-escalation and safety protocols.
B. Order the client to sit down or face seclusion immediately.
C. Turn away to avoid reinforcing behavior and leave the unit.
D. Ask other clients to confront the behavior.
B. Order the client to sit down or face seclusion immediately.
C. Turn away to avoid reinforcing behavior and leave the unit.
D. Ask other clients to confront the behavior.
Rationale
Correct answer: A. Maintain a safe distance, remove hazardous items, and follow de-escalation and safety protocols.
Rationale: Early aggression requires de-escalation, environmental safety, and staff support per mental health protocols—not confrontation or abandonment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Early aggression requires de-escalation, environmental safety, and staff support per mental health protocols—not confrontation or abandonment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.