The nurse is observing several patients who are in the activity room of the inpatient psychiatric facility. The nurse notices that one of the patients begins to get upset, raising her voice, pacing the room, and standing with clenched fists
What is the nurse's priority action?
1. Reorient the patient to person, place, and time.
2. Remove other patients from the room to provide more space.
3. Call the health care provider to obtain an order for anti-anxiety medication.
4. Call security and promptly isolate the patient and apply physical restraints.
Answer: 2
Explanation: The patient is displaying increased anxiety and aggression. Anxiety and agitation tend to escalate when there is an audience, so removing other patients to another area of the unit is a useful intervention. Removing other patients also provides safety for both the patient who is experiencing anxiety and for the other patients in the room. The patient is not displaying symptoms of altered level of consciousness or disorientation, so the primary nursing action is not to reorient the patient. Calling the health care provider for pharmacological intervention would be appropriate only after the nurse fails to achieve the desired outcome using less restrictive independent interventions. Applying physical restraints is a last resort that would not be used as a primary intervention.
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