The nurse observes that a client is psychotic, pacing, and agitated and is making aggressive gestures. The client’s speech pattern is rapid, and the client’s effect is belligerent. Based on these observations, which is the nurse’s immediate priority of care?

1. Provide safety for the client and other clients on the unit. 2. Provide the clients on the unit with a sense of comfort and safety. 3. Assist the staff with caring for the client in a controlled environment. 4. Offer the client a less-stimulating area to calm down and gain control.

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The nurse is preparing for the hospital discharge of a client with a history of command hallucinations to harm self or others. The nurse instructs the client about interventions for hallucinations and anxiety and determines that the client understands the interventions when the client makes which statement?

1. “My medications won’t make me anxious.” 2. “I’ll go to a support group and talk so that I won’t hurt anyone.” 3. “I won’t get anxious or hear things if I get enough sleep and eat well.” 4. “I can call my therapist when I’m hallucinating so I can talk about my feelings and plans and not hurt anyone.”

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