Management of Care Q 26
On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be to:
A. Give the client orientation materials and review the unit rules and regulations.
B. Introduce him/her and accompany the client to the client’s room.
C. Take the client to the day room and introduce her to the other clients.
D. Ask the nursing assistant to get the client’s vital signs and complete the admission search.
Correct Answer: B. Introduce him/herself and accompany the client to the client’s room.
Anxiety is triggered by change that threatens the individual’s sense of security. In response to anxiety in clients, the nurse should remain calm, minimize stimuli, and move the client to a calmer, more secure/safe setting.
Option A: The client is still confused and fearful. Orientation should be postponed until he is calm. They can deliver effective, safe care by assessing risk and building a rapport with the patient during the admission process; utilizing crisis prevention strategies, including appropriate medication administration, environmental, psychobiological, counseling, and health teaching interventions; and employing conflict resolution techniques.
Option C: The client should be taken to a calm environment with less stimuli so he could feel safe and become calmer.
Option D: Taking the client’s vital signs while he is still fearful would further aggravate his feelings of insecurity and fear. Utilizing the nursing process, the nurse can provide effective therapeutic interventions to promote safety for both the patient and the nurse.