A practical nurse (PN) is providing care for a veteran who recently underwent orthopedic surgery and has a documented history of post-traumatic stress disorder (PTSD). The client abruptly awakens, begins shouting commands as if in a combat zone, and forcefully throws their bedside table. Arrange the following actions the PN should take in the correct chronological order of priority.
- 1Establish a clear path to the room's exit to protect personal safety.
- 2Instruct all visitors and non-essential personnel to leave the immediate vicinity.
- 3Utilize a steady, low-pitched voice to remind the client that they are safe in the hospital.
- 4Check the client's pulse oximetry and vital signs once they have calmed down.
- 5Update the charge nurse regarding the client's behavioral escalation and response to interventions.
Answer
The correct sequence prioritizes immediate physical safety, followed by environmental control, verbal de-escalation, physiological assessment, and finally, interdisciplinary communication.
In any psychiatric emergency, crisis intervention guidelines dictate that safety is the absolute priority. The nurse must first secure their own safety by maintaining an exit path, then protect others by clearing the room. After the environment is secure, least-restrictive interventions like verbal de-escalation are applied. Only when the client is calm can physical data collection occur safely, followed by documentation and reporting to the interdisciplinary team.
Step-by-Step Solution
Key Concept
Prioritization in Psychiatric Emergencies (Safety, De-escalation, Assessment, Reporting)
Estimated Time:1m 30s