# A patient on a psychiatric inpatient unit is becoming increasingly agitated — pacing, raised voice, fists clenched but not currently striking out. Which de-escalation actions should the nurse implement? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=374880&lang=en  
> language: en  
> subject: Psychosocial Integrity  
> category: PSI

## Question

A patient on a psychiatric inpatient unit is becoming increasingly agitated — pacing, raised voice, fists clenched but not currently striking out. Which de-escalation actions should the nurse implement? Select all that apply.

1

Provide adequate personal space (at least an arm's length plus), do not block the exit, and ensure both you and the patient have a clear path out of the room.

2

Maintain a calm, low tone of voice and use simple, brief, non-confrontational language; offer the patient choices to restore a sense of control.

3

Apply physical restraints immediately to prevent escalation, as verbal de-escalation is unlikely to be effective once the patient is pacing and clenching fists.

4

Offer PRN medication (such as oral lorazepam) per protocol with the goal of voluntary acceptance, framing it as help rather than control.

5

Move other patients away to reduce stimulation, request additional staff support quietly, and keep the team visible at a safe distance for backup.

## Explanation

De-escalation: calm low voice, simple language, offer choices, adequate personal space, do not block exit, reduce stimulation, request team backup, offer PRN medication voluntarily. Choice 3 is wrong — physical restraint is the LAST resort, not the first; verbal de-escalation, environmental modification, and voluntary medication should be tried first per Joint Commission and CMS standards.

## In-depth explanation

The "Verbal de-escalation first" principle is one of the most-tested NCLEX psych points. Restraint comes last after verbal/environmental/voluntary interventions fail. The "exit access" rule protects both staff and patient — never block the door, and ensure the patient has space to retreat as anxiety releases.

## Clinical scenario

**Adult patient on inpatient psychiatric unit**: pacing, voice raised, **fists clenched but not currently striking out**. Other patients in the milieu. The nurse leads the team in de-escalation following least-restrictive principles.

## Key concepts

- **Verbal de-escalation** — First-line response to agitation: calm voice, simple language, choices, validation, personal space.
- **Restraint as last resort** — Used only when verbal and voluntary interventions fail and risk of harm is imminent; with provider order and continuous monitoring.
- **Exit access principle** — Both nurse and patient must have a clear path to exit; nurse never blocks the door.

## Related questions

- [A patient with bipolar I disorder on chronic lithium therapy presents to the ED after seve…](https://mymerci.kr/pages/nclex_q.php?qn_id=372860&lang=en)
- [A patient with severe contamination obsessive-compulsive disorder is starting exposure and…](https://mymerci.kr/pages/nclex_q.php?qn_id=372864&lang=en)
- [A 19-year-old patient is admitted with severe anorexia nervosa: BMI 13.5, heart rate 38, B…](https://mymerci.kr/pages/nclex_q.php?qn_id=373260&lang=en)
- [A 28-year-old woman is at her 6-week postpartum visit. The Edinburgh Postnatal Depression …](https://mymerci.kr/pages/nclex_q.php?qn_id=374202&lang=en)
- [A nurse working in a trauma-informed care (TIC) framework is caring for a patient with a h…](https://mymerci.kr/pages/nclex_q.php?qn_id=374923&lang=en)
- [A nurse is using motivational interviewing (MI) to help a patient consider changing alcoho…](https://mymerci.kr/pages/nclex_q.php?qn_id=374931&lang=en)
- [A client on day 7 of unfractionated heparin for DVT shows a platelet drop from 245 to 95 t…](https://mymerci.kr/pages/nclex_q.php?qn_id=374971&lang=en)
- [A client on apixaban for atrial fibrillation presents with intracerebral hemorrhage 90 min…](https://mymerci.kr/pages/nclex_q.php?qn_id=374979&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=374880&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=374880&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=374880&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=374880&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=374880&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._