A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first?

Correct Answer: C

Rationale: The correct answer is C: Take other clients in the area to the client lounge. This intervention prioritizes the safety and well-being of both the agitated client and other clients in the unit. By removing other clients from the potentially escalating situation, the nurse can prevent further agitation or harm. This intervention also allows the client some space and privacy to calm down without an audience, potentially reducing their agitation. Incorrect choices: A: Transport the client to the seclusion room - This is a restrictive measure and should only be used as a last resort for safety reasons. B: Quietly approach the client with additional staff members - Approaching an agitated client may escalate the situation, especially if the client is refusing medication. D: Administer medication to chemically restrain the client - Chemical restraint should only be used as a last resort and must follow specific protocols and guidelines. It should not be the first intervention attempted.

Correct Answer: A

Rationale: The correct answer is A because Risperidone is an atypical antipsychotic that primarily works by blocking dopamine and serotonin receptors in the brain, which helps to reduce hallucinations, delusions, and other psychotic symptoms. This mechanism of action does not directly relate to improving thinking clarity, reducing anxiety, stabilizing mood, or improving sleep, making options B, C, and D incorrect.

Correct Answer: D

Rationale: The correct answer is D because the most crucial goal for a client with major depression on antidepressants is to ensure their safety and prevent self-harm. Monitoring for suicidal ideation and behavior is a top priority. Ventilating feelings of sadness (A) is important but not as critical as ensuring safety. Eating three meals a day (B) and participating in group meetings (C) are important for overall well-being but do not directly address the immediate safety concern of potential suicide attempts.

Correct Answer: A

Rationale: The correct answer is A: Teach him to limit sugar and caffeine intake. This is the best option as excessive sugar and caffeine consumption can worsen anxiety symptoms. By reducing intake, it can help stabilize mood and energy levels. Choice B of encouraging a vacation may provide temporary relief but does not address the root cause of anxiety. Choice C of recommending financial counseling focuses solely on the financial aspect, not the physical factors contributing to anxiety. Choice D of administering PRN antianxiety medication should be a last resort and not the initial intervention.

Correct Answer: A

Rationale: The correct answer is A because it exemplifies the defense mechanism of projection, where one attributes their unacceptable thoughts or feelings to others. In this case, the individual is shifting blame onto the police for being in the psychiatric facility. Choice B is incorrect as it demonstrates rationalization rather than projection. Choice C is incorrect as it reflects denial rather than projection. Choice D is incorrect as it represents displacement rather than projection.