The nurse is caring for a client with a disturbance in thought process who is disoriented and aggressive. Which of the following nursing actions may produce further agitation?
A) Speaking in slow, brief sentences
B) Presenting the reality of the situation
C) Allowing the client freedom in a confined area
D) Being present without speaking
B
Feedback:
When caring for a client with a disturbed thought process, presenting the reality of a situation may create conflict and confusion. Also, this can lead to a verbal exchange and escalation in agitation by the client. Actions by the nurse include attempts to decrease tension and anxiety such as speaking in slow, brief sentences so the client can comprehend instructions. Allow the client freedom when maintaining a safe environment. Being present to support and assist the client without speaking is less likely to produce agitation.
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