What is the nurse’s priority action when a male client with schizophrenia arrives at the ED?

What is the nurse’s priority action when a male client with schizophrenia arrives at the ED?

• A. Administering medication
• B. Observing and evaluating his behavior
• C. Talking to his spouse
• D. Documenting the admission details

Answer: (B)

In the scenario where a male client with schizophrenia arrives at the emergency department (ED), the nurse's priority action is to observe and evaluate his behavior. This approach is crucial for several reasons. First, individuals with schizophrenia may exhibit a range of symptoms, including hallucinations, delusions, disorganized thinking, and impaired insight, which can significantly affect their behavior and level of safety. By observing and assessing the client's behavior, the nurse can determine the severity of the condition, identify any immediate risks to the client or others, and understand the need for urgent interventions. Second, this initial assessment allows the nurse to establish a baseline of the client's mental status and to identify any potential medical or psychiatric emergencies that may require immediate attention, such as suicidal ideation or aggressive behaviors. While administering medication, talking to family members, and documenting details are all important aspects of patient care, these actions would follow the critical step of ensuring that the client is stable and not in acute distress. Assessing the client's behavior enables the nurse to prioritize care based on the immediate needs identified during the evaluation, ensuring that safety is maintained in the ED setting.

In the scenario where a male client with schizophrenia arrives at the emergency department (ED), the nurse's priority action is to observe and evaluate his behavior. This approach is crucial for several reasons.

First, individuals with schizophrenia may exhibit a range of symptoms, including hallucinations, delusions, disorganized thinking, and impaired insight, which can significantly affect their behavior and level of safety. By observing and assessing the client's behavior, the nurse can determine the severity of the condition, identify any immediate risks to the client or others, and understand the need for urgent interventions.

Second, this initial assessment allows the nurse to establish a baseline of the client's mental status and to identify any potential medical or psychiatric emergencies that may require immediate attention, such as suicidal ideation or aggressive behaviors.

While administering medication, talking to family members, and documenting details are all important aspects of patient care, these actions would follow the critical step of ensuring that the client is stable and not in acute distress. Assessing the client's behavior enables the nurse to prioritize care based on the immediate needs identified during the evaluation, ensuring that safety is maintained in the ED setting.