hard · NCLEX-RN Management of Care

The RN is caring for a client with a psychiatric diagnosis who is exhibiting increasing agitation and verbal aggression. Which nursing actions are appropriate? Select all that apply.

  1. Assign the LPN/VN to administer a PRN dose of haloperidol for acute agitation.
  2. Delegate the one-to-one observation for safety to a trained AP.
  3. Perform a comprehensive suicide risk assessment using a validated tool.
  4. Evaluate the client's response to de-escalation techniques used by the staff.
  5. Direct the AP to decide when the client no longer requires seclusion or restraints.

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