Difficulty: Medium
Average Score: 91%
Simulated
A client is becoming increasingly agitated, anxious, and tense. The nurse notes a clenched jaw and a change in the pitch of the clientÔÇÖs voice. Which of the following interventions should the nurse implement first?
Correct answer
D
Rationale
Verbal de-escalation is the least restrictive first step to manage agitation safely. Restraints (A), medication (B), and seclusion (C) escalate intervention levels.