Psychiatric Assessment and Fundamentals Q 7
Nurse Anna can minimize agitation in a disturbed client by:
A. Increasing stimulation.
B. Limiting unnecessary interaction.
C. Increasing appropriate sensory perception.
D. Ensuring constant client and staff contact.
Correct Answer: B. Limiting unnecessary interaction
Limiting unnecessary interaction will decrease stimulation and agitation. Keep immediate surroundings low in stimuli (dim lighting, few people, simple decor); a stimulating environment may increase the level of anxiety. Reassure the client of his or her safety and security; this can be conveyed by the physical presence of the nurse; do not leave the client alone at this time.
Option A: Move the client to a quiet area with minimal stimuli such as a small room or seclusion area (dim lighting, few people, and so on.) Anxious behavior escalates by external stimuli. A smaller or secluded area enhances a sense of security as compared to a large area which can make the client feel lost and panicked.
Option C: Maintain a calm, non-threatening manner while working with the client. Anxiety is contagious and may be transferred from health care provider to client or vice versa. The client develops a feeling of security in presence of a calm staff person. Avoid asking or forcing the client to make choices. The client may not make sound and appropriate decisions or may be unable to make decisions at all.
Option D: Maintain calmness in your approach to the client. The client will feel more secure if you are calm and if the client feels you are in control of the situation. Observe for increasing anxiety. Assume a calm manner, decrease environmental stimulation, and provide temporary isolation as indicated. Early detection and intervention facilitate modifying a client’s behavior by changing the environment and the client’s interaction with it, to minimize the spread of anxiety.