NCLEX-RNPsychosocial IntegrityMedium
A client with a history of schizophrenia and recent medication non-adherence is brought to the emergency department by family members. The client is agitated, speaking incoherently, and believes the television is sending them secret messages. Which nursing intervention is the priority?
- AAdminister an oral antipsychotic medication as prescribed.
- BEnsure the client's immediate safety and the safety of others.
- CAttempt to reorient the client to reality by discussing current events.
- DObtain a detailed history from the family regarding medication adherence.
Show answer & explanationAnswer & explanation
Correct answer: B. Ensure the client's immediate safety and the safety of others.
In a situation involving an agitated client with psychosis, the priority is always to ensure the safety of the client and others present. This aligns with the 'Safety' component of Maslow's hierarchy and the ABCs of nursing care.
Why the other options are wrong
- A. While medication is important, safety must be established first, especially if the client is agitated and potentially a danger to themselves or others.
- C. Attempting to reorient a client experiencing active psychosis can increase agitation and is not the priority over safety.
- D. Gathering detailed history is important for treatment planning but must be deferred until immediate safety concerns are addressed.
Safety Priority in Psychosis
When a client is experiencing acute psychosis with agitation, the primary nursing intervention is to ensure immediate physical safety for the client and those around them.
- Agitation increases risk of harm.
- Safety precedes other interventions.
- De-escalation techniques are often part of ensuring safety.
Memory trick: Safety First, then Soothe the Mind.