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Question

Difficulty: EasySubstance Use and Other Disorders

A client undergoing alcohol detoxification suddenly becomes extremely agitated, paces the hallway, and begins yelling aggressively at staff. Which of the following is the priority action for the practical nurse?

  1. Ensure a safe distance and remove other clients from the immediate areaAnswer
  2. B
    Attempt to logically explain the unit rules regarding appropriate behavior to the client
  3. C
    Apply physical restraints immediately to prevent the client from injuring others
  4. D
    Discuss the client's outburst with the family in the waiting room to understand the cause

Answer

Ensure a safe distance and remove other clients from the immediate area
During an acute behavioral crisis, such as severe agitation related to alcohol withdrawal, the nurse's immediate priority is safety. Ensuring a safe distance prevents staff injury, and removing other clients from the area protects vulnerable bystanders. This creates a secure environment to then initiate verbal de-escalation or request assistance.

Step-by-Step Solution

1
Assess the situation for immediate danger.
The client is actively agitated, aggressive, and unpredictable.
Identifying the active phase of a crisis determines the appropriate immediate nursing intervention.
2
Determine the absolute priority of care.
Safety of the client, the staff, and bystanders is the highest priority.
During active behavioral escalation, physiological and physical safety supersede communication or therapeutic processing.
3
Select the safest immediate intervention.
Maintaining a safe distance and clearing the area of potential victims is the correct initial action.
This minimizes the risk of injury while preparing for further de-escalation or pharmacological intervention.

Key Concept

Crisis Intervention and Safety in Substance Use Disorders
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Topics

Substance Use and Other Disorders

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