Which client in a psychiatric unit needs immediate therapeutic intervention from the nurse?
ExplanationA. This client is demonstrating increased agitation and poses an immediate threat to the safety of other clients. The behavior requires immediate nursing intervention to prevent injury to self or others.
B. Although the client may be hallucinating, there is no immediate threat to self or others. The client should be monitored to ensure that the behavior does not escalate or become aggressive.
C. Although the client may be suspicious, data given do not indicate that this presents a danger to self or others.
D. Although anxious, this client does not represent a threat to self or others.
