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Difficulty: HardCrisis Intervention

A licensed practical nurse (PN) on a behavioral health unit observes a client pacing rapidly in the dayroom, clenching their fists, and muttering angrily. When the PN approaches, the client suddenly yells, "Don't come near me, or I'll hurt you!" and picks up a heavy plastic chair. Which action should the PN take first?

  1. Maintain a distance of at least two arm lengths and ensure a clear physical path to the exit.Answer
  2. B
    Explain to the client that threatening staff violates unit rules and will result in restricted privileges.
  3. C
    Ask the client, "Why are you feeling so angry and threatened by the staff right now?"
  4. D
    Call for the emergency response team to immediately apply four-point physical restraints.

Answer

The immediate priority is to maintain a distance of at least two arm lengths and ensure a clear physical path to the exit.
The immediate priority during an active behavioral crisis involving a physical threat is safety. Maintaining a distance of at least two arm lengths prevents sudden physical contact, and keeping a clear path to the exit ensures the nurse is not trapped in the room. Only after establishing a safe physical boundary can the nurse safely call for help or attempt brief, clear verbal de-escalation.

Step-by-Step Solution

1
Assess the client's behavior and the immediate environment.
The client is exhibiting signs of imminent violence by issuing a verbal threat and holding a potential weapon (the chair).
Identifying the specific phase of the crisis determines the safest and most appropriate intervention.
2
Prioritize immediate physical safety.
The nurse establishes a safe distance and secures an unobstructed escape route.
Personal and client safety supersedes therapeutic dialogue or limit-setting when there is an active, immediate physical threat.
3
Prepare for subsequent de-escalation or emergency response.
The nurse is positioned safely to use brief, directive verbal de-escalation while signaling for the crisis team.
Safe positioning allows for the implementation of least restrictive interventions without risking severe injury to the staff.

Key Concept

Crisis De-escalation and Environmental Safety
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Topics

Crisis Intervention

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