A patient who was responding to auditory hallucinations earlier in the morning now approaches the nurse shaking a fist and shouts, "Back off!" and then goes to the dayroom. While following the patient into the dayroom, the nurse should
A) make sure there is adequate physical space between the nurse and patient.
B) move into a position that places the patient close to the door.
C) maintain one arm's length distance from the patient.
D) begin talking to the patient about appropriate behavior.

Question

Quizplus · Accepted Answer

Making sure space is present between the nurse and the patient avoids invading the patient's personal space. Personal space needs increase when a patient feels anxious and threatened. Allowing the patient to block the nurse's exit from the room may result in injury to the nurse. Closeness may be threatening to the patient and provoke aggression. Sitting is inadvisable until further assessment suggests the patient's aggression is abating. One arm's length is inadequate space.

A Patient Who Was Responding to Auditory Hallucinations Earlier in the Morning