Registered Practical Nurse (RPN) Practice Test

In response to an agitated and hallucinating client, what action should the nurse take to ensure safety?

1. Provide constant reassurance

2. Notify the physician about potential aggression

3. Administer antipsychotic medication

4. Remove the client from the unit

The correct answer is: Notify the physician about potential aggression

Notifying the physician about potential aggression is an appropriate action in this scenario as it ensures that the client receives the necessary care and assessment from a medical professional. When a client is agitated and experiencing hallucinations, there is a heightened risk for unpredictable behavior, which may lead to harm to themselves or others. By communicating this concern to the physician, the nurse engages the wider healthcare team in assessing the client’s condition and determining the most appropriate interventions to ensure safety. This step allows for timely intervention strategies to be implemented, which may include medication adjustments or additional support from mental health professionals. Providing constant reassurance, while supportive, may not address the immediate safety concerns or medical needs of the client. Administering antipsychotic medication can only occur after proper assessment and orders from a physician, and it might not address the immediate requirement for safety assessment. Removing the client from the unit could lead to further distress or confusion, potentially escalating the situation without proper support. Thus, notifying the physician is essential for comprehensive care and safety.