The nurse observes a withdrawn schizophrenic sitting alone and moving her lips as if she is talking, but there is no audible sound. The nurse speaks to the patient by name, but the patient does not seem to hear
What action by the nurse is indicated initially? a. Hug the patient's shoulders, say, "Hey, Mary! Are you praying?"
b. Document patient's nonresponsiveness and continued detached behavior.
c. Sit down in the chair next to the patient and touch her arm, say, "I am right here, Mary."
d. Touch the patient's shoulder, then join another group of patients.
C
Sitting with the patient and touching her presents the reality of the nurse's presence. Continued attention will make the patient feel safe. Feelings of safety are needed in the beginning of the nurse–patient relationship. Hugging the patient may invade the patient's personal space. The nurse's assessment will be documented but it is most appropriate to attempt an interaction with the patient.
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