NCLEX-PN® ExaminationPsychosocial IntegrityMedium
A practical nurse is caring for a client who is exhibiting signs of escalating agitation, including pacing, clenched fists, and a loud voice. Which of the following is the most appropriate initial nursing intervention?
- ACall for assistance from security personnel.
- BAdminister a PRN sedative as ordered.
- CMaintain a calm demeanor and speak in a low, clear voice.
- DTell the client to stop the behavior immediately.
Show answer & explanationAnswer & explanation
Correct answer: C. Maintain a calm demeanor and speak in a low, clear voice.
Maintaining a calm demeanor and speaking in a low, clear voice helps de-escalate the situation by not mirroring the client's agitation and providing a sense of control and safety. This is a primary de-escalation technique.
Why the other options are wrong
- A. Calling for security is appropriate if the client becomes violent or poses an immediate threat, but not as an initial response to agitation.
- B. Administering medication may be necessary if de-escalation fails, but it's not the initial intervention.
- D. Demanding a client stop often escalates agitation and challenges their autonomy, making the situation worse.
De-escalation Techniques: Initial Response
Initial de-escalation involves using calm, non-threatening communication and demeanor to reduce a client's agitation and prevent escalation to violence.
- Prioritize safety for client and staff.
- Maintain personal space.
- Use active listening and empathy.
Memory trick: Calmly Assess, Speak Slowly, Maintain Space, Offer Choices.