hard · NCLEX-RN Psychosocial Integrity
Sequence the nurse's actions in order of priority from first to last to safely de-escalate the client's agitation. Base the response on this specific EHR: "setting": "Psychiatric Inpatient Unit", "client": "28-year-old male with a history of PTSD and trauma", "observation": "The client begins pacing rapidly in the hallway, clenches his fists, raises his voice, and states,.
- Maintain a physical distance of at least two arm-lengths and ensure clear access to an exit.
- Acknowledge the client's feelings of distress with a calm, low, and non-threatening tone.
- Offer the client a concrete, simple choice between sitting in a quiet lounge or resting in their room.
- Administer the ordered PRN oral lorazepam to chemically stabilize agitation.
- Document the agitation event, interventions implemented, and the client's response.
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