A client who has been seen responding to auditory hallucinations earlier in the morning approaches

Question

the nurse and shakes his fist, saying "Back off, bitch!" and then goes into the day room. The nurse
follows the client into the day room.

The nurse should
a. move to a position that allows the client to be closest to the door.
b. make sure physical space is present between herself and the client.
c. position herself within an arm's length of the client.
d. sit down in a chair near the client.

Answer 1

B
Making sure space is present between the nurse and the client avoids invading the client's personal
space. Personal space needs increase when a client feels anxious and threatened. Option A: Allowing
the client to block the nurse's exit from the room is not wise. Option C: This closeness may be
threatening to the client and provoke aggression. Option D: Sitting is inadvisable until further
assessment suggests the client's aggression is abating.