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Difficulty: Very hardCrisis Intervention

An adolescent client is receiving care on a medical-surgical unit following an intentional medication overdose. While the practical nurse is taking routine vital signs, the client abruptly stands up, forcefully knocks over the bedside table, and retreats into the corner of the room. The client picks up a jagged piece of broken plastic from the damaged table, points it outward, and yells, "Stay away from me! I'll use this if you come any closer!" The nurse is currently positioned near the open doorway. Which intervention is the priority for the nurse to implement?

  1. A
    Instruct the client in a firm, authoritative voice to drop the object immediately, explaining that safety protocols must be followed before care can continue.
  2. Step back into the hallway to ensure a safe distance, maintain continuous visual observation of the client, and activate the facility's behavioral emergency response team.Answer
  3. C
    Attempt to calm the client by stating, "You have nothing to be afraid of here; please put the plastic down so we can talk about why you are feeling this way."
  4. D
    Promptly leave the area to draw up the client's prescribed as-needed (PRN) chemical restraint medication to prevent imminent self-harm.

Answer

The correct action is to step back into the hallway to ensure a safe distance, maintain continuous visual observation of the client, and activate the facility's behavioral emergency response team.
When a client is in an active crisis state and possesses a potential weapon, the absolute priority is the physical safety of the nurse and the client. By stepping back into the hallway, the nurse removes themselves from immediate physical danger and provides the client with physical space, reducing the client's feeling of being trapped. Maintaining continuous visual observation is critical because the client has a history of a recent suicide attempt and is currently armed. Activating the behavioral emergency response team ensures that personnel trained in advanced de-escalation and safe physical interventions are present to manage the situation. This approach aligns with prioritizing strict safety protocols while avoiding patient abandonment.

Step-by-Step Solution

1
Assess the immediate physical safety of the environment and the severity of the client's escalation.
The nurse recognizes that the client is armed, highly agitated, and cornered, posing an imminent risk of physical harm to both the client and the nurse.
Safety of the healthcare provider and the client is the absolute priority in any crisis intervention scenario involving a potential weapon.
2
Determine the appropriate level of intervention based on the phase of the crisis.
Because the client is in the active escalation phase and possesses a weapon, verbal de-escalation alone or physical limit-setting is currently unsafe and unlikely to be effective.
Logical reasoning and therapeutic communication are ineffective when a client's 'fight or flight' response is fully activated and they are actively threatening violence.
3
Select the action that maximizes physical safety while ensuring the vulnerable client is not abandoned.
The nurse steps back into the hallway, keeps the client in sight, and calls for the specialized behavioral emergency response team.
This maintains a safe physical distance, prevents the client from feeling further trapped, ensures continuous observation of an at-risk client, and brings appropriate trained resources to manage the threat.

Key Concept

Prioritizing physical safety and appropriate interdisciplinary escalation during an active behavioral crisis involving a weapon.
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Topics

Crisis Intervention

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