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Difficulty: HardBehavioral Interventions

The practical nurse is working on a busy telemetry unit. A client admitted with acute confusion abruptly leaves their room, grabs a heavy IV pole from the hallway, and begins swinging it toward the nurses' station while shouting aggressively. What is the priority nursing action?

  1. A
    Approach the client slowly with open hands and attempt to rationally discuss why they are angry.
  2. Direct all nearby personnel and clients to immediately clear the hallway area.Answer
  3. C
    Call for unit staff to physically secure the client and rapidly apply mechanical restraints.
  4. D
    Issue a firm ultimatum that hospital security will be called if the pole is not dropped immediately.

Answer

The correct action is to direct all nearby personnel and clients to immediately clear the hallway area.
When a client becomes an immediate physical threat by weaponizing a heavy object, the absolute first priority is to ensure the safety of others in the milieu. Evacuating the area removes potential targets, increases distance, and creates a safer environment while hospital security or a specialized behavioral crisis response team is notified.

Step-by-Step Solution

1
Assess the immediate physical threat level in the environment.
The client has weaponized a heavy object and is actively swinging it, posing an imminent danger to life and safety.
Behavioral interventions must strictly follow safety priorities; active violence requires a different response than verbal agitation.
2
Prioritize milieu safety above all other interventions.
Evacuating the area prevents injury to innocent bystanders, visitors, and unit staff.
When a client is in an active, physically dangerous escalation phase, removing potential targets and creating physical distance is the absolute first action before mobilizing a specialized crisis team.

Key Concept

Crisis Agitation De-escalation and Milieu Safety
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Topics

Behavioral Interventions

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