Tony, age 21, has been diagnosed with schizophrenia. He has been socially isolated and hearing voices telling him to kill his parents. He has been admitted to the psychiatric unit from the emergency department. The initial nursing intervention for Tony is to:

Correct Answer: B

Rationale: The correct answer is B: Ensure a safe environment for him and others. This is the initial nursing intervention because safety is the top priority when dealing with a patient experiencing psychotic symptoms like Tony. By ensuring a safe environment, we can prevent harm to Tony and others. Giving him an injection of Thorazine (choice A) is not the initial step as safety takes precedence. Placing him in restraints (choice C) should only be considered as a last resort for immediate danger. Ordering him a nutritious diet (choice D) is important for his overall well-being but not the immediate priority in this situation.

Correct Answer: C

Rationale: The correct approach is to call for sufficient help first (choice C) because it prioritizes safety for both the client and staff. By calling for help, the nurse can ensure that there are enough resources to safely manage the aggressive behavior and prevent harm. This approach allows for a team effort in de-escalating the situation and controlling it effectively. Providing large motor activities (choice A) may not be appropriate during an aggressive outburst as it can escalate the situation. Administering medication (choice B) should not be the first response as it does not address the underlying cause of the aggression. Conveying to the client that their behavior is unacceptable (choice D) may further agitate the client and is not likely to de-escalate the situation effectively.

Correct Answer: D

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: D

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.