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Difficulty: HardMental Health Concepts

A client receiving inpatient treatment for post-traumatic stress disorder (PTSD) suddenly becomes severely agitated in the communal lounge. The client begins overturning chairs, pacing aggressively, and shouting about an imminent attack. Which actions are appropriate for the practical nurse (PN) to implement? Select all that apply.

  1. Position oneself to maintain an unobstructed pathway to the nearest exit doorAnswer
  2. B
    Attempt to verbally de-escalate by providing a detailed rationale of the unit's safety protocols
  3. Adopt a non-threatening body posture and speak using a calm, low-pitched toneAnswer
  4. D
    Tell the client that they are perfectly safe and there is absolutely nothing to worry about
  5. E
    Prepare to administer the client's prescribed as-needed (PRN) intravenous (IV) push sedative
  6. Coordinate with other nursing staff to clear all uninvolved peers from the lounge area immediatelyAnswer

Answer

The correct actions are positioning oneself to maintain an unobstructed exit pathway, adopting a non-threatening posture while speaking in a calm tone, and coordinating with staff to clear uninvolved peers from the area.
The correct actions prioritize immediate physical safety for both the staff and the milieu while utilizing established non-pharmacological de-escalation techniques. Maintaining a clear exit path and removing uninvolved peers prevents injury during a severe behavioral crisis. Using a calm, low-pitched voice with an open posture helps reduce the client's autonomic arousal without posing a physical or psychological threat.

Step-by-Step Solution

1
Assess the immediate environment for physical safety risks to staff and bystanders.
Staff secure an exit path and remove other clients from the immediate vicinity.
During an acute behavioral escalation, ensuring physical safety for the milieu is the absolute first priority before attempting individual psychosocial interventions.
2
Determine the appropriate communication style for a highly agitated client experiencing a flashback.
A calm, low-pitched tone and open posture are utilized by the nurse.
Loud, authoritative, or confrontational communication can exacerbate the autonomic fight-or-flight response in a client with PTSD.
3
Identify the practical nurse (PN) scope of practice regarding pharmacological de-escalation.
IV push medications are excluded from the PN's planned interventions.
Administering IV push medications requires RN-level licensure and is strictly outside the PN scope of practice, regardless of client acuity.

Key Concept

Mental Health Concepts: Crisis Intervention and PN Scope of Practice
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Mental Health Concepts

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