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Question

Difficulty: MediumBehavioral Interventions

The practical nurse (PN) is monitoring the day room at a behavioral health rehabilitation center. A client abruptly stands up, forcefully knocks a chair to the floor, and begins shouting aggressively at a visiting family member. Which action should the PN take first?

  1. Direct the family member to leave the room while maintaining a safe physical distance from the clientAnswer
  2. B
    Explain to the client that loud outbursts are unacceptable and violate facility rules
  3. C
    Ask the client, 'Why are you suddenly feeling so angry toward your visitor?'
  4. D
    Prepare to administer a prescribed as-needed (PRN) intramuscular sedative to prevent physical harm

Answer

The correct answer is to direct the family member to leave the room while maintaining a safe physical distance from the client.
During an active behavioral crisis involving physical displays of aggression, the priority is immediate safety. Removing the target of the aggression (the visitor) from the environment and maintaining a safe physical distance is the most effective, least-restrictive initial action to protect others and begin de-escalating the milieu.

Step-by-Step Solution

1
Analyze the client's current behavioral state.
The client is in an active, escalating behavioral crisis characterized by verbal hostility and physical aggression (knocking over a chair).
Identifying the phase of escalation dictates the appropriate level of intervention.
2
Determine the immediate priority of care.
The physical safety of the client, the visitor, and the staff supersedes therapeutic dialogue or limit-setting.
Safety is always the primary concern during active aggression.
3
Select the most appropriate least-restrictive safety intervention.
Removing the visitor from the environment and keeping a safe distance addresses the immediate threat without escalating the conflict.
This aligns with the least-restrictive intervention hierarchy and milieu safety principles.

Key Concept

Crisis Intervention and Milieu Safety
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Topics

Behavioral Interventions

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