Question

The client is trembling and appears fearful as he enters a locked behavioral health unit for the first time. Which initial action by the nurse would be best for the client?

A. Ask a mental health technician to take the client to his room and measure vital signs
B. Introduce self to the client and accompany the client to his room
C. Give the client orientation information and review the unit rules and regulations
D. Take the client to the community day room and introduce him to everyone

Answer 1

The best initial action by the nurse for a fearful client entering a behavioral health unit is to introduce herself and escort him to his room, focusing on patient-centered care and establishing a therapeutic rapport.

Step-by-step explanation:

The initial action by the nurse that would be best for a client who is trembling and appears fearful as he enters a locked behavioral health unit for the first time is to introduce herself to the client and accompany the client to his room. This approach prioritizes patient-centered care and establishes therapeutic rapport, providing a sense of security and personalized attention. The nurse's presence can be reassuring and offers an opportunity for the client to express any immediate concerns or fears.

Immediately orienting the client to the rules or introducing him to a large group of people in the day room could be overwhelming and add to his anxiety. Taking vital signs is important, but this should be done after ensuring the client is as comfortable as possible in the new environment. Understanding the client's situation involves assessing his orientation and awareness, which includes knowing the time, place, and personal identity, as well as the context of his current circumstances.