Final answer:
The nurse should first remove all other clients from the day room to ensure their safety, then check the medical record for an as needed medication order, administer it if available, and report to the physician if necessary. Restraints are a last resort.
Step-by-step explanation:
The nurse's first action when a client becomes extremely agitated and exhibits aggressive behavior by cursing and throwing furniture should be to ensure the safety of all individuals, which aligns with the fourth option given. Therefore, the nurse should:
- Remove all other clients from the day room to prevent any injuries and to de-escalate the situation.
- After securing the safety of others, the nurse should check the client's medical record for an order for an I.M. as needed dose of medication for agitation.
- If medication is available and indicated, the nurse should administer it as prescribed.
- If the situation continues or worsens, the nurse should then call the physician and report the behavior.
- Using restraints, such as full leather restraints, is typically a last resort due to the risks involved and should only be considered when all other de-escalation techniques have failed and if there is an imminent risk to the client or others.
Neuroleptic drugs like haloperidol (Haldol) are often used to reduce agitation, aggression, and psychotic symptoms. While the patient may initially experience slowed responses and drowsiness, neuroleptics do not typically impair cognitive function at standard doses and are particularly effective in reducing psychotic symptoms over time.