A practical nurse (PN) is caring for a client in a substance use disorder treatment facility. The client suddenly becomes highly agitated, begins pacing the hallway, and shouts threats about leaving the facility immediately. What is the correct priority sequence of actions the PN should take? Arrange the actions in the correct order from first to last.
- 1Ensure personal safety by keeping a safe distance and maintaining a clear path to the exit.
- 2Attempt verbal de-escalation by speaking in a calm, non-judgmental tone.
- 3Request assistance from additional staff members if the agitation persists.
- 4Notify the registered nurse (RN) or charge nurse about the client's behavior.
- 5Document the incident, the client's exact statements, and the actions taken.
Answer
The correct sequence is: Ensure personal safety, attempt verbal de-escalation, request assistance from staff, notify the RN, and finally document the incident.
In any acute behavioral crisis, the first priority is always safety, starting with the nurse ensuring a clear path to the exit. Once the nurse's safety is established, attempting least restrictive interventions like verbal de-escalation is the next step. If de-escalation fails, the nurse must call for immediate staff backup. Once the immediate threat is managed, the PN must report the acute change to the RN for further clinical decision-making. Finally, after the client and environment are secure, accurate documentation of the event is completed.
Step-by-Step Solution
Key Concept
Prioritization of safety and de-escalation in acute behavioral crises.