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Difficulty: MediumCrisis Intervention

A practical nurse (PN) is working the night shift in a residential substance use detoxification center. A client in the common area suddenly becomes intensely agitated, pacing erratically with clenched fists. The client shouts, "I cannot take this anymore! If someone does not give me something to calm down right now, I am going to lose it!" and forcefully kicks a chair toward the medication window. Which of the following is the priority action for the PN to take?

  1. A
    Attempt to reason with the client by explaining that medications can only be administered according to the current prescribed schedule.
  2. Ensure personal safety by establishing physical distance from the client, verifying a clear exit route, and activating the facility's emergency response team.Answer
  3. C
    Ask the client, "Why do you feel the need to threaten the staff rather than discussing what is making you so upset?"
  4. D
    Immediately retrieve and prepare soft limb restraints with the assistance of other staff to prevent the client from causing further property damage.

Answer

The correct action is to ensure personal safety by establishing physical distance from the client, verifying a clear exit route, and activating the facility's emergency response team.
During an active behavioral crisis involving escalating agitation and potential violence, the absolute highest priority is ensuring the physical safety of the nurse, other staff, and clients. This is accomplished by maintaining a safe distance, securing an escape route, and calling for trained assistance.

Step-by-Step Solution

1
Identify the client's current phase of crisis based on their behavior.
The client is in the active escalation phase, demonstrating physical aggression (kicking a chair) and verbal threats.
Assessing the level of risk determines the immediate nursing intervention required.
2
Determine the primary goal in an active crisis situation.
The absolute priority is the immediate physical safety of all individuals in the environment.
Safety supersedes all other therapeutic interventions (such as exploring feelings or explaining rules) during an acute escalation.
3
Select the action that best supports the primary goal of safety.
Establishing physical distance, securing an unblocked exit, and activating the emergency response team ensures safety and brings appropriate resources to the situation.
A single nurse should not attempt to physically manage, corner, or argue with an actively aggressive client.

Key Concept

Crisis Intervention Safety Priorities
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Topics

Crisis Intervention

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