ATI MENTAL HEALTH 1 ( Complete Questions and answers) A+ Rated.

ATI MENTAL HEALTH 1 1. As a nurse approaches a client with schizophrenia, the client looks at the nurse and says, “Back off. Leave me alone.” The client appears tense and is pacing rapidly. Which of the following is an appropriate nursing response? a. “I can’t leave you alone when you are this upset. Sit down, and try to relax.” b. “Let’s go to your room, and you can tell me what is bothering you.” c. “I will give you space as long as you control yourself. I’d like to know what is causing you to feel so tense.” d. “I will leave you alone for a few minutes while you try to compose yourself.” The nurse’s first concern is to ensure safety. To avoid escalating the client’s behavior, the nurse should stay at the comfortable distance and remain calm while stressing the importance of maintaining control. Verbal intervention is the least restrictive form of action. If the client does not respond to verbal interventions, then more restrictive measures may have to be used.